目的:大多数表现为髋部骨折的患者,不管他们的合并症如何,都要接受手术治疗。越来越多的研究表明,某种类型的老年患者可以从姑息治疗中受益更多。
目的:确定从姑息治疗方法而不是手术中获益最大的患者。
方法:2015年至2021年之间的探索性匹配回顾性队列研究。
方法:单一级创伤中心。
方法:2015年至2021年间,我院收治了2240例髋部骨折患者。可以包括65岁以上的股骨粗隆间或股骨颈骨折患者。共有129名患者选择了姑息治疗(姑息治疗组=PG)。将该队列与匹配的队列进行比较(对于年龄,性别和骨折类型)接受手术但在手术后三个月内死亡(手术死亡组=SDG),另一个匹配的队列在手术后存活超过三个月(手术存活组=SAG)。
方法:对患者的人口统计学进行了医学图表审查,自治级别,护理水平,神经认知障碍(NCD),骨折类型,入院后三个月内的住院数据和门诊死亡。通过单变量和多变量模型与SASOnDemandforAcademics(α0.05)进行分析。
结果:PG患者(n=129)为88.2±7.2岁,71.3%是女性,61.2%有股骨颈骨折。SDG(n=95)和SAG(n=107)的患者匹配良好。在NCD方面,PG与SDG(n=95)和SAG(n=107)不同(85.3%vs.57.9%与36.4%,p<0.01)和痴呆的行为和心理症状(BPSD)的存在(19.4%vs.5.3%与3.7%,p<0.01)。有更多已知的心力衰竭(24.2%vs.16.3%,p<0.01)和慢性阻塞性肺疾病(COPD)在SDG组高于PG组(26.6vs.14.7%,p=0.02)。SAG患者的NCD发生率显着降低(OR2,7(95CI1,5-5,0)),心力衰竭(OR5,7(95CI1,9-16,4))和COPD(OR2,8(95CI1,2-6,3))比其他组。骨折前流动性,不同群体之间的自主性和生活状况差异显著。PG的中位生存期为6天,SDG的中位生存期为17天。所有团体都失去了自主性和机动性。SDG组比PG组有更多的并发症。PG和SDG组的大多数患者的治疗结束轨迹是死亡或临终关怀。超过30%的SAG组无法出院回家。
结论:NCD的存在和骨折前自主性的降低有力地支持了姑息治疗的咨询。对于患有多种合并症的虚弱患者,建议进行手术时,并发症的发生率很高,这表明需要重新审视姑息性手术的概念。
OBJECTIVE: Most patients presenting with a hip fracture regardless of their comorbidities are surgically treated. A growing body of research states that a certain type of elderly patient could benefit more from a palliative approach.
OBJECTIVE: Identify the patient who would benefit most from a palliative care approach instead of a surgery.
METHODS: Exploratory-matched retrospective cohort study between 2015 and 2021.
METHODS: Single Level 1 Trauma Center.
METHODS: There were 2240 hip fracture patients admitted to our institution between 2015 and 2021. Patients over 65 years old with intertrochanteric or femoral neck fractures could be included. A total of 129 patients opted for palliative care (Palliative Group = PG). This cohort was compared to a matched cohort (for age, sex and fracture type) who underwent surgery but died within three months of the procedure (Surgery Deceased Group = SDG) and another matched cohort who survived more than three months (Surgery Alive Group = SAG) following surgery.
METHODS: Medical charts were reviewed for patient demographics, autonomy level, level of care, neurocognitive disorders (NCD), fracture type, in-hospital data and outpatient death within three months of admission. Analysis was performed through univariate and multivariate models with SAS OnDemand for Academics (alpha 0.05).
RESULTS: Patients in the PG (n = 129) were 88.2 ± 7.2 years old, 71.3% were females, and 61.2% had a femoral neck fracture. Patients in the SDG (n = 95) and SAG (n = 107) were well matched. The PG differed from the SDG (n = 95) and SAG (n = 107) regarding NCD (85.3% vs. 57.9% vs. 36.4%, p < 0.01) and the presence of Behavioral and psychological symptoms of dementia (BPSD) (19.4% vs. 5.3% vs. 3.7%, p < 0.01). There were more known heart failure (24.2% vs. 16.3%, p < 0.01) and Chronic Obstructive Pulmonary Disease (COPD) in the SDG group than in the PG group (26.6 vs. 14.7%, p = 0.02). Patients in the SAG have a significant lower rate of NCD (OR 2,7 (95%CI 1,5-5,0)), heart failure (OR 5,7 (95%CI 1,9-16,4)) and COPD (OR 2,8 (95%CI 1,2-6,3)) than other groups. Prefracture mobility, autonomy and living situation significantly differed between the groups. Median survival was six days in PG and 17 days in SDG. All groups lost autonomy and mobility. There were more complications in the SDG group than in the PG group. The end-of-care trajectory was death or hospice for most patients in the PG and SDG groups. More than 30% of the SAG group could not return home at discharge.
CONCLUSIONS: The presence of an NCD and diminished prefracture autonomy strongly support counseling for palliative care. The high rate of complications when surgery is proposed for frail patients with multiple comorbidities suggests that the concept of palliative surgery needs to be revisited.