Reliability of Proxy-reported Patient-reported Outcomes Measurement Information System Physical Function and Pain Interference Responses for Elderly Patients With Musculoskeletal Injury.

BACKGROUND: Patient-reported Outcomes Measurement Information System (PROMIS) instruments are useful to evaluate health status, but its use can be challenging for some vulnerable elderly patients, requiring aid from their proxies. Whether the proxies could be accurate informants is unknown. The goal of this study was to compare elderly patients' and their proxies' answers with PROMIS physical function (PF) and pain interference (PI) computer adaptive test for the evaluation of patients' outcomes after musculoskeletal injury. In addition, to correlate patients' reported PF with the Timed Up and Go (TUG) test. METHODS: This prospective cohort study, from February to September 2016, in the Orthopaedic trauma clinic of two level I Trauma centers, included 273 patients aged 65 years or older, ambulatory, cognitively intact, with a discernible proxy. PROMIS PF and PI, TUG, and the "FRAIL" Questionnaire screening tool were performed. The correlation of PROMIS scores between patients and proxies, and also with the TUG score, was assessed using Spearman rank correlation. The Bland-Altman analysis served to check agreement and bias. Subgroup comparison was tested using probit transformations. RESULTS: The mean age of patients was 75.7 years, SD 7.5 (62.2 years; SD, 13.8 for proxies), 66.7% women, 57.1% married, and 34% with femoral fractures. A significant correlation and agreement of PROMIS PF and PI scores were found between patients and proxies (Spearman rho for both, PF and PI = 0.73), although proxies tended to overestimate the interference of pain on patient's performance (median difference, -1.7; P < 0.001). The correlation was markedly stronger in nonfrail patients and in those with faster TUG scores. There was also a correlation between patients' PROMIS PF and TUG test (Spearman rho = - 0.58). CONCLUSIONS: Proxies are good informants of the PF of ambulatory, cognitively intact elderly patients, as evaluated by the PROMIS PF instrument, after musculoskeletal injury, although they tend to slightly overestimate PI. The use of proxy-reported PROs might better characterize functional impairment and pain in a vulnerable patient population, and it could decrease selection bias in outcomes research. LEVEL OF EVIDENCE: Diagnostic level II.

FRAIL Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients.

OBJECTIVES: There are limited screening tools to predict adverse postoperative outcomes for the geriatric surgical fracture population. Frailty is increasingly recognized as a risk assessment to capture complexity. The goal of this study was to use a short screening tool, the FRAIL scale, to categorize the level of frailty of older adults admitted with a fracture to determine the association of each frailty category with postoperative and 30-day outcomes. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PARTICIPANTS: A total of 175 consecutive patients over age 70 years admitted to co-managed orthopedic trauma and geriatrics services. MEASUREMENTS: The FRAIL scale (short 5-question assessment of fatigue, resistance, aerobic capacity, illnesses, and loss of weight) classified the patients into 3 categories: robust (score = 0), prefrail (score = 1-2), and frail (score = 3-5). Postoperative outcome variables collected were postoperative complications, unplanned intensive care unit admission, length of stay (LOS), discharge disposition, and orthopedic follow-up after surgery. Thirty-day outcomes measured were 30-day readmission and 30-day mortality. Analysis of variance (1-way) and Kruskal-Wallis tests were used to compare continuous variables across the 3 FRAIL categories. Fisher exact tests were used to compare categorical variables. Multiple regression analysis, adjusted by age, sex, and Charlson index, was conducted to study the association between frailty category and outcomes. RESULTS: FRAIL scale categorized the patients into 3 groups: robust (n = 29), prefrail (n = 73), and frail (n = 73). There were statistically significant differences between groups in terms of age, comorbidity, dementia, functional dependency, polypharmacy, and rate of institutionalization, being higher in the frailest patients. Hip fracture was the most frequent fracture, and it was more frequent as the frailty of the patient increased (48%, 61%, and 75% in robust, prefrail, and frail groups, respectively). The American Society of Anesthesiologists preoperative risk significantly correlated with the frailty of the patient (American Society of Anesthesiologists score 3-4: 41%, 82% and 86%, in robust, prefrail, and frail groups, P < .001). After adjustment by age, sex, and comorbidity, there was a statistically significant association between frailty and both LOS and the development of any complication after surgery (LOS: 4.2, 5.0, and 7.1 days, P = .002; any complication: 3.4%, 26%, and 39.7%, P = .03; in robust, prefrail, and frail groups). There were also significant differences in discharge disposition (31% of robust vs 4.1% frail, P = .008) and follow-up completion (97% of robust vs 69% of the frail ones). Differences in time to surgery, unplanned intensive care unit admission, and 30-day readmission and mortality, although showing a trend, did not reach statistical significance. CONCLUSIONS: Frailty, measured by the FRAIL scale, was associated with increase LOS, complications after surgery, and discharge to rehabilitation facility in geriatric fracture patients. The FRAIL scale is a promising short screen to stratify and help operationalize the perioperative care of older surgical patients.

Epidemiology of hip fracture in the elderly in Spain.

OBJECTIVE: To describe the incidence and epidemiological characteristics of hip fracture (HF) in patients aged 65 years or over in the various autonomous regions (AR) of Spain from the year 2000 to 2002 and to determine which factors affect in-hospital mortality. METHODS: Retrospective, observational study including all patients aged >65 years with acute hip fracture in the 19 AR of Spain from 2000 to 2002. Data were obtained from the National Record of the Minimum Basic Data Set of the Ministry of Health. We analyzed the following: incidence rates (crude and age- and gender-adjusted rates) and incidence of hospital admission by season, length of hospital stay and in-hospital mortality. We used regression analysis to identify the factors that influenced in-hospital mortality. RESULTS: There were 107,718 cases of HF in patients aged >65 years; of these, 74% were women, with a mean age of 79 years (SD 14). The crude incidence rate for HF was 511 cases per 100,000 >65-year-old patients per year (265 cases per 100,000 men and 688 per 100,000 women and year). Incidence adjusted for age and gender was 503 cases per 100,000 inhabitants per year. Catalonia had the highest age-adjusted incidence and Galicia the lowest (623 and 317 cases per 100,000 inhabitants per year, respectively). Incidence rates increased from spring (24.1%) to winter (25.8%). The mean length of hospital stay was 15 days (SD 13). Seasonal influence and length of stay varied greatly between autonomous regions. While the overall in-hospital mortality rate was 5.3%, the rate for males was double that of females (8.9% and 4.8%, respectively), and in-hospital mortality increased with comorbidity (each point on the Charlson index increased mortality by 34.5%) was higher in winter (11% more risk compared to warmer seasons) and in cold climate regions (15% more risk compared to regions with a warm climate, i.e.: Catalonia, Valencia, Murcia, Andalusia, Balearic Islands and Canary Islands). CONCLUSIONS: Hip fracture mainly affects elderly women and presents great variability in incidence, seasonality, length of hospital stay and mortality between the different autonomous regions in Spain. Elderly male patients with severe comorbid conditions, who are admitted in winter and in cold climate regions are more at risk of in-hospital mortality.