Impact of Preoperative Specialty Consults on Hospitalist Comanagement of Hip Fracture Patients.

BACKGROUND: Hip fractures typically occur in frail elderly patients. Preoperative specialty consults, in addition to hospitalist comanagement, are often requested for preoperative risk assessment. OBJECTIVE: Determine if preoperative specialty consults meaningfully influence management and outcomes in hip fracture patients, while being comanaged by hospitalists DESIGN: Retrospective cohort study SETTING: Tertiary care hospital in Connecticut PATIENTS: 491 patients aged 50 years and older who underwent surgery for an isolated fragility hip fracture, defined as one occurring from a fall of a height of standing or less. INTERVENTION: Presence or absence of a preoperative specialty consult MEASUREMENTS: Time to surgery (TTS), length of hospital stay (LOS), and postoperative complications RESULTS: 177 patients had a preoperative specialty consult. Patients with consults were older and had more comorbidities. Most consult recommendations were minor (72.8%); there was a major recommendation only for eight patients (4.5%). Multivariate analysis demonstrates that consults are more likely to be associated with a TTS beyond 24 hours (Odds Ratio [OR] 4.28 [2.79-6.56]) and 48 hours (OR 2.59 [1.52-4.43]), an extended LOS (OR 2.67 [1.78-4.03]), and a higher 30-day readmission rate (OR 2.11 [1.09-4.08]). A similar 30-day mortality rate was noted in both consult and no-consult groups. CONCLUSIONS: The majority of preoperative specialty consults did not meaningfully influence management and may have potentially increased morbidity by delaying surgery. Our data suggest that unless a hip fracture patient is unstable and likely to require active management by a consultant, such consults offer limited benefit when weighed against the negative impact of surgical delay.

Impact of Resilience on Outcomes of Total Knee Arthroplasty.

BACKGROUND: Resilience, defined as the ability to bounce back from stress, has been suggested as a predictor of surgical outcomes. The purpose of this study is to examine the relationship between resilience and patient-reported outcomes following primary elective total knee arthroplasty (TKA). We hypothesized that patients exhibiting greater preoperative resilience would report better outcome scores. METHODS: A prospective cohort of 153 patients (74 male, 79 female) undergoing primary elective TKA completed questionnaires preoperatively and at 3 and 12 months following their index procedure. The validated Brief Resilience Scale was used to evaluate resilience. Hierarchical multiple linear regression was used to analyze the effect of resilience on KOOS-JR (Knee Injury and Osteoarthritis Outcome Score JR) and PROMIS-10 (Patient-Reported Outcomes Measurement Information System) outcome scores. RESULTS: At 12 months, the change in the coefficient of determination (R2) attributable to preoperative resilience was 0.101 (P < .001) and 0.204 (P < .001) for physical and mental health, respectively. Although there was expected improvement in KOOS-JR scores following TKA, the effect of baseline resilience for this outcome was not significant. When evaluating resilience measured concurrently, there was significant correlation with both 3-month and 12-month KOOS-JR and PROMIS-10 outcome scores. CONCLUSION: Preoperative resilience is a significant predictor of overall physical and mental health outcomes at both 3 and 12 months. Greater concurrent resilience predicted better scores across all outcomes. These findings suggest that major elective surgery, like other traumatic events, can cause a change in resilience. Although functional improvements after TKA are expected, those patients who exhibit greater resilience at baseline are more likely to report an improved quality of life.