Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study

Background: Hip fracture in the elderly nursing home resident is often the acute event which leads to rapid decline and death, with one study of Medicare beneficiaries revealing a 36% mortality rate at 180 days.¹ However, nonoperative management is rarely presented as an acceptable option to patients and families and patient-centric outcomes of operative versus nonoperative management are not well known. 

Design and Participants: This Dutch multihospital prospective study of frail nursing home patients older than 70 years who suffered a proximal hip fracture sought to evaluate whether nonoperative management was noninferior to operative management in measures of health related quality of life. The primary outcome was determined by the EuroQOL Dimension (EQ-5D) questionnaire (lower scores worse QOL) and secondary outcomes used a dementia specific QOL instrument. Satisfaction of proxies and caregivers with their treatment choice was measured and the Quality of Dying and Death Questionnaire was administered to the proxies of patients who died. Decision about operative versus nonoperative treatment was made using shared decision making after discussing advantages and disadvantages to each approach with patient, proxies or relatives, and relevant health care providers.

Results: Median age of the 172 patient subjects was 88 years; 78% were women. 88 patients chose nonoperative management compared to 84 who chose surgery. Health related QOL was determined not inferior in the nonoperative group as compared to the operative group as measured weekly over 4 weeks (and was not compared beyond 4 weeks because less than 10 subjects remained alive in the nonoperative group). The QOL scores were compared between the two groups using linear mixed-effects regression models. A noninferiority margin of 0.15 points of the 95% confidence interval of the EQ-5D score was used. Proxies and caregivers rated the QOL visual analog score significantly lower in nonoperative patients compared to operative patients.  Of surgical survivors, 50% were totally dependent for ADLs at 3 months, diminishing slightly to 41% at 6 months. Mobility was severely compromised by the hip fracture with 89% of nonoperative patients being bedbound. Although 79% of the surgical patients had been mobile pre-fracture, only 29% regained mobility over the 6 months of the study. After 1 week, more patients in the nonoperative group experienced pain (88% vs. 67%, p=0.001), but at 2 weeks, there was no difference (55% vs. 53%, p>0.99). However, nonoperative patients received higher daily doses of morphine at all timepoints compared to the operative patients. Adverse events such as pressure ulcers and delirium were more common in the surgical patients. Mortality at 30 days was 83% in nonoperative group vs 25% in surgical patients; at 6 months, mortality was 94% and 48%, respectively. In both groups, proxies and health care providers were highly satisfied with the treatment choice. Of the patients who died during the study, proxies and health care providers of the nonoperative patients were more satisfied with treatment choice. Of the patients who died, 51% of proxies of nonoperative patients rated death “quality” as good-almost perfect whereas 62% of proxies of surgical patients rated it intermediate quality.

Commentary: This study disproved the null hypothesis that nonoperative management of hip fracture in the elderly, frail, institutionalized patient is inferior to surgical management with respect to health related QOL. Despite a very high 30 day mortality, proxies and health care providers were very satisfied with the nonoperative treatment choice and with the quality of death. Given these findings, the nonoperative treatment option should be offered more frequently to select patients similar to those in the study. Additionally, the nearly 50% mortality at 6 months of patients who opted for surgery should be disclosed to patients/families during decision-making. An unexplained finding of the study that merits further investigation is why in the nonoperative group did patients who did not experience pain receive statistically equivalent doses of morphine to those who did experience pain? The study does not discuss whether nonoperative patients had initiation of CMO nor does it discuss the cultural mores of CMO status in the Netherlands. Demographically, this was a study of a very homogenous population of very old, White women living in institutions in the Netherlands. It is unclear how generalizable are the results to the U.S. population. Because nursing home care in the Netherlands is state-funded and because all patients have health insurance, financial motives likely did not affect treatment choice. In the U.S., however, the fee-for-service model may incentivize surgeons to tout surgical options to these patients. Additionally, complex financial motives (e.g., family financial obligations to SNF care, exhausted Medicare reimbursed rehabilitation days) may motivate proxies toward one choice or another. Further investigation is necessary, too, to determine patient/proxy attitudes in the U.S. regarding the willingness to tolerate the invasiveness of surgery for a short term survival benefit.  Finally, in the U.S., decision-making discussions about acute surgery for nursing home residents generally involve the family/proxy and the surgeon and rarely incorporate the opinion of health care providers who know the patient at the facility. Whether shared decision making could incorporate a gerontologist with a pre-existing relationship to the patient remains to be studied.

Bottom Line: In frail, elderly nursing home residents who suffer proximal hip fracture, health related quality of life for patients choosing nonoperative management is not inferior to surgical management. When patients arrive at hospital after this injury, shared decision making should include honest disclosure about the high mortality rate and low mobility recovery, even among patients who opt for surgery. Nonoperative, symptom targeted management should be discussed as feasible and likely leading to a rapid, satisfactory dying experience. 

References: If needed 1. Neuman MD, Silber JH, Magaziner JS, et al. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med. 2014;174(8):1273.

Source: The reference for the article in AMA style Loggers SA, Willems HC, van Balen R, et al. Evaluation of quality of life after nonoperative or operative management of proximal femoral fractures in frail institutionalized patients: the FRAIL-HIP study. JAMA Surg. 2022;157(5):424-434.