Repair of Proximal Humerus Fracture Linked to Worse Outcomes in Elderly

By Anne Harding

NEW YORK (Reuters Health) - Higher rates of surgery for proximal humerus fracture among Medicare beneficiaries are associated with increased costs, adverse events, and mortality, according to new findings in JAMA Network Open.

Risks were especially high for older, sicker, or frailer patients, Dr. Sarah B. Floyd of the Arnold School of Public Health at the University of South Carolina in Greenville and colleagues found.

"Orthopedic surgeons should be cautioned of the harms of extending the use of surgery to more clinically vulnerable patient subgroups," Dr. Floyd told Reuters Health in an email. "A reduction in surgery rates could reduce mortality and adverse event rates for patients with proximal humerus fracture."

The risks and benefits of surgical treatment for this injury are heterogenous, meaning it is essential to establish the effective rate of surgery across patients, Dr. Floyd and her team note in their report. Given the "substantial and persistent geographic variation" in rates of surgery for proximal humerus fracture, they add, there is no apparent consensus on what this rate should be.

The authors looked at all fee-for-service Medicare beneficiaries with this fracture in 2011, a total of 72,823 patients, using an instrumental variable approach to analyze the association between surgery rates, adverse events, mortality risk and cost.

Surgery rates ranged from 1.8% to 33%. Higher rates of surgery were associated with higher costs in the year after surgery. Each 1% increase in surgery rate was associated with a 0.09 percentage point increase in adverse events and a 0.09 percentage point rise in mortality, while one-year adverse event rates increased by 0.19 percentage points for each 1% increase in the surgery rate. Risks were more pronounced for patients with more comorbidities, higher frailty index scores, and those 80 and older.

According to risk-adjusted estimates, costs were $17,278 higher for surgical patients, while adverse event rates increased 0.12 percentage points with each 1% increase in surgery rate. However, each 1% increase in surgery was linked to a 0.01 percentage point drop in annual mortality.

The findings underscore the value of using observational data to answer research questions, Dr. Floyd said. "Our study produced evidence from real-world data of the implications of higher surgery rates for proximal humerus fracture. Our results provide very policy-relevant conclusions about the implications of changing surgical treatment rates."

She and her colleagues are conducting a similar study within their health system that will include data on the clinical complexity of fractures.

"We also have multiple proposals in review to continue to study the treatment of proximal humerus fracture in the Medicare population, and discover how best to put evidence into physicians' hands when treatment decisions are being made," Dr. Floyd said.

SOURCE: https://bit.ly/388Ml11 JAMA Network Open, online January 10, 2020.

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