BACKGROUND: Most evidence guiding perioperative medical risk management of patients undergoing hip fracture repair focuses on cardiac and thromboembolic risk. Little is known of the relative clinical importance of other complications. OBJECTIVE: To systematically map incidence and outcomes of a broad spectrum of medical complications after hip fracture repair. METHODS: Retrospective cohort study of patients 60 years or older in 20 academic, community, and Veterans Affairs hospitals. Data on complications and mortality were abstracted from medical records by trained abstractors using standardized, pretested forms or the National Death Index. RESULTS: Of 8930 patients, 1737 (19%) had postoperative medical complications. Cardiac and pulmonary complications were most frequent (8% and 4% of patients, respectively). Similar numbers of patients had serious cardiac or pulmonary complications (2% and 3%, respectively). Other complications were gastrointestinal tract bleeding (2%), combined cardiopulmonary complications (1%), venous thromboembolism (1%), and transient ischemic attack or stroke (1%). Renal failure and septic shock were rare. After the index complication, 416 patients had 587 additional complications. Mortality was similar for serious cardiac or pulmonary complications (30 day: 22% and 17%, respectively; 1 year: 36% and 44%, respectively) and highest for patients with multiple complications (30 day: 29%-38%; 1 year: 43%-62%). Complications and death occurred significantly earlier for serious cardiac than for serious pulmonary complications (1 vs 4 days, 2 vs 8 days, P<.001); length of stay for patients surviving these complications was similar. CONCLUSIONS: Most patients had no medical complications after hip fracture repair. Serious cardiac and pulmonary complications were equally important in frequency, mortality, and survivors' length of stay. Patients with multiple complications had especially poor prognosis.

Aged↗

PubMed2002

Prognostic judgments and triage decisions for patients with acute congestive heart failure.

STUDY OBJECTIVES: To determine how well triage physicians judge the probability of death or severe complications that require treatment only available in an ICU to maintain life for patients with acute congestive heart failure (CHF). DESIGN: Prospective cohort study. SETTING: An urban university hospital, a Veteran's Administration hospital, and a community hospital. PATIENTS OR PARTICIPANTS: Patients were those visiting the emergency department (ED) with acute CHF, excluding those who already required a treatment only available in an ICU to maintain life, and those with possible or definite myocardial infarction. Physician participants were those caring for the patients in the ED. MEASUREMENTS AND RESULTS: We performed chart reviews to ascertain whether each patient died or had severe complications develop by 4 days. We collected judgments of the probability of this outcome from the physicians taking care of the study patients in the ED. The prevalence of death or severe complications was 43 per 1,032 patients (4.2%). The mean +/- SD of physicians' judgments of the probability of this outcome was 32.1 +/- 28.4%. A calibration curve that stratified these judgments by decile demonstrated that physicians consistently overestimated this probability (p < 0.01). Physicians' judgments were only moderately good at discriminating which patients would have the outcome (receiver operating characteristic curve area, 0.715). Patients admitted to an ICU received the highest average predicted probability (56.4%), followed by those admitted to a telemetry unit (34.1%), to a regular hospital ward (29.8%), and those sent home (17.9%.) CONCLUSIONS: Physicians drastically overestimated the probability of a severe complication that would require critical care for patients with acute CHF who were candidates for ICU admission. Their judgments of this probability were associated with their triage decisions, as they should be according to several guidelines for ICU triage. Overestimation of the probability of severe complications may have lead to overutilization of scarce critical care resources. Current critical care triage guidelines should be revised to take this difficulty into account, and better predictive models for patients potentially requiring critical care should be developed.

Acute Disease↗

PubMed2002

Physicians' judgments of survival after medical management and mortality risk reduction due to revascularization procedures for patients with coronary artery disease.

STUDY OBJECTIVE: s: To assess the accuracy of physicians' judgments of survival probability for medically managed patients with coronary artery disease (CAD), and of the absolute risk reduction of mortality due to coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) for such patients; and relationships among these judgments and the physicians' propensity to perform revascularization. DESIGN: Two surveys (for three-vessel or two-vessel CAD) for patients presenting with stable CAD, currently managed medically, and without other life-limiting problems. SETTING: Multiple educational conferences, 1996-1997. PARTICIPANTS: Conference attendees. MEASUREMENTS AND RESULTS: Main outcomes were proportions of patients for whom the physicians would recommend revascularization (CABG for three-vessel CAD, CABG or PTCA for two-vessel CAD), and judgments of the proportions of medically managed patients who would be alive after 5 years, 7 years, and 11 years, and of absolute risk reduction of mortality due to CABG (or PTCA for two-vessel CAD). At least one half of the participants judged the survival rate of medically managed patients with three-vessel or two-vessel CAD to be less than the lowest rates supported by the best available evidence. More than one fourth judged the absolute risk reduction due to CABG to be higher than the highest values based on such evidence. Physicians' propensity to perform revascularization correlated inversely with their judgments of survival given medical management, and with their judgments of absolute risk reduction due to revascularization. CONCLUSIONS: Physicians may overuse revascularization because of excessive pessimism about survival of medically managed patients, and excessive optimism about the survival benefits of revascularization.

Angioplasty, Balloon, Coronary↗

PubMedDate not supplied

Nurse telemanagement improved outcomes and reduced cost of care more than home nurse visits in chronic heart failure.

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