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.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic.

Objectives: To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. Design: Retrospective cohort study. Setting: Academic medical center. Patients/Participants: Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). Intervention: Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. Main Outcome Measurements: Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). Results: In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. Conclusions: All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. Level of Evidence: III.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic

Objectives: To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. Design: Retrospective cohort study. Setting: Academic medical center. Patients/Participants: Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February–May 2019) and during COVID (February–May 2020). Intervention: Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. Main Outcome Measurements: Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). Results: In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID− patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. Conclusions: All patients, including COVID− patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. Level of Evidence: III

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected.

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

COVID-19 Vaccination Improved Outcomes in the Treatment of Geriatric Hip Fractures Between December 2020 and January 2022.

INTRODUCTION: Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. METHODS: Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. RESULTS: The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. DISCUSSION: In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

Seasonality Affects Elderly Hip Fracture Mortality Risk During the COVID-19 Pandemic

Background The incidence of geriatric hip fractures, respiratory infections (e.g., coronavirus disease 2019 (COVID-19), influenza), and mortality is higher during the fall and winter. The purpose of this study is to assess whether the addition of seasonality to a validated geriatric inpatient mortality risk tool will improve the predictive capacity and risk stratification for geriatric hip fracture patients. We hypothesize that seasonality will improve the predictive capacity. Methodology Between October 2014 and August 2021, 2,421 patients >55-year-old treated for hip fracture were analyzed for demographics, date of presentation, COVID-19 status (for patients after February 2020), and mortality. Patients were grouped by season based on their admission dates into the following four cohorts: fall (September-November), winter (December-February), spring (March-May), and summer (June-August). Patients presenting during the fall/winter and spring/summer were compared. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMAHIP_FX_SCORE) and the seasonality iteration (STTGMA_SEASON) were also compared. Sub-analysis was conducted on 687 patients between February 2020 and August 2021 amid the COVID-19 pandemic. The baseline score (STTGMAHIP_FX_SCORE) and the COVID-19 iteration (STTGMACOVID_ORIGINAL_2020) were modified to include seasonality (STTGMA_COVID/SEASON). Patients were stratified by risk score and compared. The predictive ability of the models was compared using DeLong’s test. Results For the overall cohort, patients who presented during the fall/winter had a higher rate of inpatient mortality (2.87% vs. 1.25%, p < 0.01). STTGMA_SEASON improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE but not significantly (0.773 vs. 0.672, p = 0.105) On sub-analysis, regression weighting showed a coefficient of 0.643, with fall and winter having a greater absolute effect size (fall = 2.572, winter = 1.929, spring = 1.286, summer = 0.643). STTGMA_COVID/SEASON improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.882 vs. 0.581, p < 0.01) and STTGMACOVID_ORIGINAL_2020 (0.882 vs. 0.805, p = 0.04). The highest risk quartile contained 89.5% of patients who expired during their index inpatient hospitalization (p < 0.01) and 68.2% of patients who died within 30 days of discharge (p < 0.01). Conclusions Seasonality may play a role in both the incidence and impact of COVID-19 and additional respiratory infections. Including seasonality improves the predictive capacity and risk stratification of the STTGMA tool during the COVID-19 pandemic. This allows for effective triage and closer surveillance of high-risk geriatric hip fracture patients by better accounting for the increased respiratory infection incidence and the associated mortality risk seen during fall and winter.

Hip Fracture Volume Does Not Change at a New York City Level 1 Trauma Center During a Period of Social Distancing.

PURPOSE: To characterize the volume and variation in orthopedic consults and surgeries that took place during a period of social distancing and pandemic. METHODS: All orthopedic consults and surgeries at an urban level 1 trauma center from 3/22/20-4/30/2020 were retrospectively reviewed (the social distancing period). Data from the same dates in 2019 were reviewed for comparison. Age, gender, Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) score and injury type were queried. Operating room data collected included: type of surgery performed, inpatient or outpatient status, and if the cases were categorized as elective, trauma or infectious cases. RESULTS: Compared to 2019, there was a 48.3% decrease in consult volume in 2020. The 2020 population was significantly older (44.0 vs 52.6 years-old, p = 0.001) and more male (65% vs 35%, p = 0.021). There were 23 COVID positive patients, 10 of which died within the collection period. Consult distribution dramatically changed, with decreases in ankle fractures, distal radius fractures and proximal humerus fractures of 76.5%, 77.4% and 55.0%, respectively. However, there was no significant difference in volume of hip, tibial shaft and femoral shaft fractures (p > 0.05). In 2020, there was a 41.4% decrease in operating room volume, no elective cases were performed, and cases were primarily trauma related. CONCLUSIONS: During a period of pandemic and social distancing, the overall volume of orthopedic consults and surgeries significantly declined. However, hip fracture volume remained unchanged. Patients presenting with orthopedic injuries were older, and at higher risk for inpatient mortality.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective.

OBJECTIVES: To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN: Prospective cohort study. SETTING: Seven musculoskeletal care centers within New York City and Long Island. PATIENTS/PARTICIPANTS: One hundred thirty-eight recent and 115 historical hip fracture patients. INTERVENTION: Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-). MAIN OUTCOME MEASUREMENTS: Hospital quality measures, inpatient complications, and mortality rates. RESULTS: Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively. CONCLUSIONS: COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.