Retrospective Cohort Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Dec 18, 2017; 8(12): 902-912
Published online Dec 18, 2017. doi: 10.5312/wjo.v8.i12.902
Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture
Ethan Y Brovman, Andrew J Pisansky, Anair Beverly, Angela M Bader, Richard D Urman
Ethan Y Brovman, Andrew J Pisansky, Anair Beverly, Angela M Bader, Richard D Urman, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, United States
Richard D Urman, Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA 02115, United States
Author contributions: Brovman EY, Pisansky AJ, Beverly A and Urman RD developed study concept and design; Pisansky AJ and Beverly A wrote the manuscript; Brovman EY contributed to data extraction and statistical analysis; Bader AM and Urman RD contributed to supervision and comments.
Institutional review board statement: The study was reviewed and approved by the Brigham and Women’s Hospital Institutional Review Board.
Informed consent statement: Informed consent waiver was granted by the institutional IRB.
Conflict-of-interest statement: None of the authors has received fees for serving as a speaker, a consultant, or advisory board member relevant to the present manuscript. Richard Urman has received research funding from Harvard Medical School and the Center for Perioperative Research that helped support his time for developing the manuscript. All authors are employees of Brigham and Women’s Hospital, Boston, MA 02115, United States. None of the authors own stocks or patents related to the content of the manuscript.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at rurman@bwh.harvard.edu.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Richard D Urman, MD, Associate Professor, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, United States. rurman@bwh.harvard.edu
Telephone: +1-617-7328210
Received: July 11, 2017
Peer-review started: July 14, 2017
First decision: September 4, 2017
Revised: October 30, 2017
Accepted: November 28, 2017
Article in press: November 28, 2017
Published online: December 18, 2017
Processing time: 160 Days and 3 Hours
Abstract
AIM

To determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures.

METHODS

We conducted a propensity score matched retrospective analysis using de-identified data from the American College of Surgeons’ National Surgical Quality Improvement Project (ACS NSQIP) for all patients undergoing hip fracture surgery over a 7 year period in hospitals across the United States enrolled in the ACS NSQIP with and without DNR status. We measured patient demographics including DNR status, co-morbidities, frailty and functional baseline, surgical and anaesthetic procedure data, post-operative morbidity/complications, length of stay, discharge destination and mortality.

RESULTS

Of 9218 patients meeting the inclusion criteria, 13.6% had a DNR status, 86.4% did not. Mortality was higher in the DNR compared to the non-DNR group, at 15.3% vs 8.1% and propensity score matched multivariable analysis demonstrated that DNR status was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, analysis of the propensity score matched cohort demonstrated that DNR status was associated with a significant, but very small increased likelihood of post-operative complications (0.53 vs 0.43 complications per episode; OR = 1.21; 95%CI: 1.04-1.41, P = 0.004). Cardiopulmonary resuscitation and unplanned reintubation were significantly less likely in patients with DNR status.

CONCLUSION

While DNR status patients had higher rates of post-operative complications and mortality, DNR status itself was not otherwise associated with increased morbidity. DNR status appears to increase 30-d mortality via ceilings of care in keeping with a DNR status, including withholding reintubation and cardiopulmonary resuscitation.

Keywords: Do-Not-Resuscitate; Consent; Perioperative; Outcomes; Mortality; Hip fracture

Core tip: We present a large, multi-institution retrospective cohort study which examines the independent association of Do-Not-Resuscitate (DNR) status with perioperative outcomes during hip fracture surgery. We find that DNR status independently predicts overall rates of complications and mortality at 30 d without other clear sources of morbidity. Our conclusions place this work in the context of other literature on the outcomes for patients with DNR status during the perioperative period, exploring the data among other surgical populations and hypotheses for this effect.