Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture

Table 1 Demographics, co-morbidities and functional baseline of Do-Not-Resuscitate and non-Do-Not-Resuscitate status patients undergoing hip fracture surgery

Category	DNR			Not DNR			OR (95%CI)	P values
	Num	Denom	%	Num	Denom	%
Age, mean (SD)	85.1		6.7	77.55		12.3	1.098 (1.088-1.109)	< 0.001
< 65	26	1256	2.1	1188	7962	14.9	Reference	< 0.001
65-80	169	1256	13.5	2384	7962	29.9	3.239 (2.131-4.923)
> 80	1061	1256	84.5	4390	7962	55.1	11.043 (7.445-16.381)
Sex
Male	313	1254	25.0	2395	7950	30.1	Reference	< 0.001
Female	941	1254	75.0	5555	7950	69.9	1.296 (1.131-1.486)
Demographics
White	781	1215	64.3	6008	7544	79.6	Reference	< 0.001
Black	11	1215	0.9	371	7544	4.9	0.228 (0.125-0.417)
Asian	3	1215	0.2	94	7544	1.2	0.246 (0.078-0.777)
Other	4	1215	0.3	31	7544	0.4	0.993 (0.349-2.819)
Not reported	416	1215	34.2	1040	7544	13.8	3.077 (2.686-3.525)
Hispanic	18	824	2.2	314	6677	4.7	0.453 (0.28-0.732)	0.001
BMI
Mean (SD)	24.1		5.5	25.3		6.5	0.966 (0.953-0.978)	< 0.001
< 18.5	110	913	12.0	630	7076	8.9	1.261 (1.007-1.579)	< 0.001
18.5-25	454	913	49.7	3279	7076	46.3	Reference
25-30	244	913	26.7	1976	7076	27.9	0.892 (0.756-1.052)
> 30	105	913	11.5	1191	7076	16.8	0.637 (0.51-0.795)
Functional status
No dyspnea	1098	1256	87.4	7136	7961	89.6	Reference	0.015
Dyspnea with moderate exertion	116	1256	9.2	652	7961	8.2	1.156 (0.94-1.423)
Dyspnea at rest	42	1256	3.3	173	7961	2.2	1.578 (1.12-2.224)
Independent	491	1251	39.2	4726	7917	59.7	Reference	< 0.001
Partially dependent	579	1251	46.3	2583	7917	32.6	2.158 (1.896-2.456)
Totally dependent	181	1251	14.5	608	7917	7.7	2.865 (2.369-3.466)
ASA class
1 or 2	108	1256	8.6	1739	7951	21.9	0.388 (0.315-0.478)	< 0.001
3	779	1256	62.0	4866	7951	61.2	Reference
4 or 5	369	1256	29.4	1346	7951	16.9	1.712 (1.492-1.965)
Comorbidities
Hypertension	908	1256	72.3	5413	7962	68.0	1.229 (1.076-1.402)	0.002
Diabetes	184	1256	14.7	1468	7962	18.4	0.759 (0.643-0.897)	0.001
COPD	181	1256	14.4	899	7962	11.3	1.323 (1.114-1.571)	0.001
CHF	55	1256	4.4	234	7962	2.9	1.512 (1.12-2.041)	0.006
CAD	212	1256	16.9	1340	7962	16.8	1.004 (0.856-1.176)	0.966
PVD	25	1256	2.0	235	7962	3.0	0.668 (0.44-1.013)	0.056
CKD	29	1256	2.3	214	7962	2.7	0.856 (0.578-1.267)	0.436
Stroke	229	1256	18.2	1023	7962	12.8	1.512 (1.292-1.771)	< 0.001
Weight loss	31	1256	2.5	119	7962	1.5	1.668 (1.118-2.488)	0.011
Sepsis	204	1249	16.3	931	7892	11.8	1.46 (1.238-1.721)	< 0.001
Recent surgery	12	1256	1.0	114	7962	1.4	0.664 (0.365-1.207)	0.177
Labs
Creatinine	1.09		0.8	1.08		0.9	1.015 (0.946-1.088)	0.664
Hematocrit	30.7			30.1			1.01 (0.986-1.034)	0.394
Platelets	212			208			1.04 (0.977-1.107)	0.196
Surgical urgency
Emergent	428	1256	34.1	2194	7962	27.6	1.359 (1.197-1.542)	< 0.001
Surgical complexity
Work RVU	17.45		2.0	17.46		2.7	0.998 (0.975-1.021)	0.841
Anesthesia
General	796	1255	63.4	6028	7959	75.7	NA	< 0.001
Neuraxial/regional	446	1255	35.5	1876	7959	23.6	1.8 (1.586-2.044)
Other	13	1255	1.0	55	7959	0.7	1.79 (0.974-3.291)
Anesthesia time	117.9		48.1	128.8		58.5	0.996 (0.995-0.997)	< 0.001
Operation time	61.4		43.8	70.2		43.5	0.994 (0.992-0.996)	< 0.001
Modified Charlson score	2.44		1.4	2.03		1.5	1.207 (1.16-1.255)	< 0.001

DNR: Do-Not-Resuscitate; BMI: Body mass index; SD: Standard deviation; ASA: American Society of Anesthesiologists; COPD: Chronic obstructive pulmonary disease; CHF: Congestive heart failure;CAD: Coronary artery disease; PVD: Peripheral vascular disease; CKD: Chronic kidney disease; RVU: Relative value unit.

Table 2 Surgical case mix of hip fracture surgery performed on Do-Not-Resuscitate and non Do-Not-Resuscitate status patients after propensity matching

CPT code	Translation	DNR			Not DNR			P value
		num	denom	%	num	denom	%
27236	Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement	210	725	28.966	223	725	30.759	0.994
27245	Treatment of intertrochanteric, per-trochanteric, or sub-trochanteric femoral fracture; with intramedullary implant	173	725	23.862	171	725	23.586
27125	Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)	111	725	15.31	104	725	14.345
27244	Treatment of intertrochanteric, per-trochanteric, or sub-trochanteric femoral fracture; with plate/screw type implant, with or without cerclage	91	725	12.552	99	725	13.655
27235	Percutaneous skeletal fixation of femoral fracture, proximal end, neck	48	725	6.621	44	725	6.069
27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty)	20	725	2.759	19	725	2.621
27248	Open treatment of greater trochanteric fracture, with or without internal or external fixation	9	725	1.241	5	725	0.69
27506	Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws	8	725	1.103	12	725	1.655
27187	Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur	6	725	0.828	4	725	0.552
27454	Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (e.g., Sofield type procedure)	5	725	0.69	4	725	0.552
27507	Open treatment of femoral shaft fracture with plate/screws, with or without cerclage	5	725	0.69	8	725	1.103
27511	Open treatment of femoral supracondylar or trans-condylar fracture without intercondylar extension, with or without internal or external fixation	5	725	0.69	6	725	0.828
27228	Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation	3	725	0.414	4	725	0.552
27513	Open treatment of femoral supracondylar or trans-condylar fracture with intercondylar extension, with or without internal or external fixation	3	725	0.414	1	725	0.138
27122	Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure)	2	725	0.276	2	725	0.276
27138	Revision of total hip arthroplasty	2	725	0.276	2	725	0.276
27165	Osteotomy, intertrochanteric or sub-trochanteric, including internal or external fixation and/or cast	2	725	0.276	0	725	0
27509	Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or trans-condylar, with or without intercondylar extension, or distal femoral epiphyseal	2	725	0.276	1	725	0.138
27132	Conversion of previous hip surgery to total hip arthroplasty	1	725	0.138	1	725	0.138
27134	Revision of total hip arthroplasty	1	725	0.138	0	725	0
27254	Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external fixation	1	725	0.138	1	725	0.138
27450	Osteotomy, femur, shaft or supracondylar; with fixation	1	725	0.138	3	725	0.414
27514	Open treatment of femoral fracture, distal end, medial or lateral condyle, with or without internal or external fixation	1	725	0.138	1	725	0.138

DNR: Do-Not-Resuscitate.

Table 3 Propensity score matched case mix of procedures and the distribution within Do-Not-Resuscitate and non-Do-Not-Resuscitate status groups

	Do-Not-Resuscitate			Not Do-Not-Resuscitate			OR (95%CI)	P-values
Category	Num	Denom	%	Num	Denom	%
Age, mean (SD)	85.1	NA	6.7	85.0	NA	6.5	1.001 (0.985-1.016)	0.946
< 65	17	725	2.3	18	725	2.5	Reference	0.982
65-80	92	725	12.7	93	725	12.8	1.047 (0.508-2.158)
> 80	616	725	85.0	614	725	84.7	1.062 (0.542-2.081)
Sex
Male	177	725	24.4	165	725	22.8	Reference	0.458
Female	548	725	75.6	560	725	77.2	0.912 (0.716-1.163)
Demographics
White	692	725	95.4	689	725	95.0	Reference	0.462
Black	6	725	0.8	4	725	0.6	1.493 (0.42-5.316)
Asian	3	725	0.4	9	725	1.2	0.332 (0.089-1.231)
Other	3	725	0.4	2	725	0.3	1.493 (0.249-8.966)
Not Reported	21	725	2.9	21	725	2.9	0.996 (0.539-1.84)
Hispanic	17	725	2.3	17	725	2.3	1 (0.506-1.974)	1
BMI
Mean (SD)	24.1	NA	5.6	24.3	NA	5.4	0.996 (0.977-1.015)	0.646
< 18.5	90	725	12.4	88	725	12.1	0.999 (0.719-1.389)	0.901
18.5-25	350	725	48.3	342	725	47.2	Reference
25-30	198	725	27.3	211	725	29.1	0.917 (0.718-1.171)
> 30	87	725	12.0	84	725	11.6	1.012 (0.724-1.415)
Functional status
No Dyspnea	614	725	84.7	608	725	83.9	Reference	0.899
Dyspnea with moderate exertion	77	725	10.6	80	725	11.0	0.953 (0.684-1.329)
Dyspnea at rest	34	725	4.7	37	725	5.1	0.91 (0.564-1.469)
Independent	267	725	36.8	269	725	37.1	Reference	0.938
Partially Dependent	342	725	47.2	336	725	46.3	1.025 (0.818-1.286)
Totally Dependent	116	725	16.0	120	725	16.6	0.974 (0.717-1.323)
ASA class
1 or 2	47	725	6.5	49	725	6.8	0.955 (0.627-1.455)	0.977
3	444	725	61.2	442	725	61.0	Reference
4 or 5	234	725	32.3	234	725	32.3	0.995 (0.796-1.245)
Comorbidities
Hypertension	547	725	75.4	555	725	76.6	0.941 (0.74-1.198)	0.623
Diabetes	120	725	16.6	113	725	15.6	1.074 (0.812-1.422)	0.617
COPD	112	725	15.4	117	725	16.1	0.949 (0.716-1.259)	0.719
CHF	36	725	5.0	40	725	5.5	0.895 (0.563-1.421)	0.637
CAD	147	725	20.3	159	725	21.9	0.905 (0.703-1.165)	0.44
PVD	17	725	2.3	23	725	3.2	0.733 (0.388-1.384)	0.336
CKD	16	725	2.2	12	725	1.7	1.341 (0.63-2.855)	0.445
Stroke	137	725	18.9	139	725	19.2	0.982 (0.756-1.277)	0.894
Weight loss	21	725	2.9	20	725	2.8	1.051 (0.565-1.957)	0.874
Sepsis	148	725	20.4	152	725	21.0	0.967 (0.75-1.247)	0.795
Recent surgery	5	725	0.7	6	725	0.8	0.832 (0.253-2.739)	0.762
Labs
Creatinine	1.13		0.8	1.11		0.7	1.034 (0.897-1.192)	0.646
Hematocrit	33.3			34.6			0.868 (0.765-0.985)	0.017
Platelet count	210			206			1.067 (0.94-1.211)	0.313
Surgical urgency
Emergent	181	725	25.0	175	725	24.1	1.046 (0.823-1.328)	0.714
Surgical complexity
Work RVU	17.4		2.2	17.5		2.1	0.988 (0.942-1.036)	0.622
Anesthesia
General	562	725	77.5	557	725	76.8	Reference	0.568
Neuraxial/Regional	162	725	22.3	168	725	23.2	0.956 (0.748-1.222)
Other	1	725	0.1	0	725	0.0	1 (-∞-∞)
Anesthesia Time	122.0	NA	49.4	123.6	NA	49.7	0.999 (0.997-1.001)	0.55
Operation Time	63.9	NA	34.0	64.7	NA	36.1	0.999 (0.996-1.002)	0.645
Modified Charlson Score	2.6	NA	1.4	2.59	NA	1.4	1.007 (0.936-1.084)	0.852

DNR: Do-Not-Resuscitate; BMI: Body mass index; SD: Standard deviation; ASA: American Society of Anesthesiologists; COPD: Chronic obstructive pulmonary disease; CHF: Congestive heart failure;CAD: Coronary artery disease; PVD: Peripheral vascular disease; CKD: Chronic kidney disease; RVU: Relative value unit.

Table 4 Thirty-days outcomes after hip fracture surgery in DNR and non-DNR status patients

Outcomes	DNR			Not DNR			OR (95%CI)	P values
	Num	Denom	%	Num	Denom	%
Death	111	725	15.3	59	725	8.1	2.04 (1.459-2.851)	< 0.001
Reoperation/return to OR	22	725	3.0	17	725	2.3	1.309 (0.689-2.487)	0.417
Failure to wean from ventilator	4	725	0.6	7	725	1.0	0.558 (0.161-1.934)	0.364
Reintubation	5	725	0.7	19	725	2.6	0.253 (0.093-0.688)	0.004
Superficial SSI	10	725	1.4	0	725	0.0	21.294 (1.245-364.078)	0.002
Deep incisional SSI	3	725	0.4	2	725	0.3	1.466 (0.242-8.901)	0.654
Organ/space SSI	2	725	0.3	2	725	0.3	1.011 (0.142-7.196)	1
Wound Dehiscence	1	725	0.1	0	725	0.0	3.00 (0.122-73.870)	0.317
Pneumonia	25	725	3.4	34	725	4.7	0.725 (0.428-1.23)	0.232
Acute kidney injury	3	725	0.4	4	725	0.6	0.754 (0.168-3.383)	0.705
Renal failure requiring dialysis	3	725	0.4	2	725	0.3	1.5 (0.249-9.034)	0.654
CVA	4	725	0.6	5	725	0.7	0.798 (0.213-2.994)	0.738
Cardiac arrest with CPR	2	725	0.3	16	725	2.2	0.115 (0.025-0.523)	0.001
Acute MI	16	725	2.2	13	725	1.8	1.245 (0.594-2.608)	0.574
Transfusion	169	725	23.3	139	725	19.2	1.243 (0.964-1.603)	0.054
Venous thromboembolism	9	725	1.2	14	725	1.9	0.621 (0.265-1.457)	0.293
UTI	45	725	6.2	41	725	5.7	1.061 (0.683-1.649)	0.657
Sepsis	14	725	1.9	23	725	3.2	0.595 (0.303-1.17)	0.134
Number of complications	Mean		SD	Mean		SD	OR (95%CI)	P-values
	0.53		0.65	0.43		0.61	1.213 (1.043-1.409)	0.004
Length of hospital stay	Mean		SD	Mean		SD	HR (95%CI)	P-values
	6.4		5.0	6.74		5.3	2.133 (0.469-0.871)	0.219

DNR: Do-Not-Resuscitate; OR: Operating room; SSI: Surgical site infection; CVA: Cerebrovascular accident; CPR: Cardiopulmonary resuscitation; MI: Myocardial infarction; UTI: Urinary tract infection.