Exploring multidisciplinary decision‐making factors for geriatric trauma patients: An observational real‐life clinical study

The aging population leads to an increase in frail older patients at risk of hip fractures, raising mortality rates, and healthcare costs.1, 2 Orthogeriatrics has improved outcomes, but frail older patients still face high mortality.3 Decisions on whether these patients should receive surgery or non-operative care are complex and influenced by factors like cognitive impairment and the acute and unplanned nature of their injuries.4-6 Although comprehensive geriatric assessments reduce surgery rates, and non-operative care is ethically sound for very frail older patients, decision-making for geriatric trauma patients outside of institutional care still faces important knowledge gaps.7, 8 We aimed to describe documented factors in multidisciplinary team (MDT) discussions of older adults referred for consideration of surgical versus non-operative management of hip fractures. Consecutive hip fracture patients from a Dutch level-1 trauma center, who were discussed in MDT meetings for potential non-operative treatment between 2019 and 2021 were included. Inclusion was based on high (≥10) Almelo Hip Fracture Score (AHFS) or physician discretion.9 Data included demographics, clinical status, length of stay, and mortality. Factors influencing decision-making were extracted from the electronic patient file by two independent reviewers. Statistical analyses included interobserver agreement (Cohen's Kappa) and regression analyses to investigate the factors associated with the triage decision. The institutional review board of MUMC approved the study with a waiver of consent. Table 1 summarizes the characteristics of 104 hip fracture patients. Fifty-eight (55.8%) patients went for surgery; the remaining 46 (44.2%) received non-operative treatment with the latter more likely to be nursing home residents, being unable to walk independently, higher pressure ulcer risk, cognitive problems, and higher American Society of Anesthesiologists (ASA) physical status classifications. Patient preferences were found to be considered in only 33.7% of cases, whereas other factors like comorbidity (68.3%), baseline mobility (57.7%), cognitive function (45.2%), and quality of life (41.3%) were more commonly considered in MDT meetings. The interobserver agreement was substantial for most factors. The incidences of all factors and their reliability (Cohen's Kappa) are summarized in Supplementary Table S1. Table 2 shows the factors influencing the decision between non-operative treatment (ORs >1) and surgery (ORs <1). In the univariable analysis, an increased risk of pressure ulcers, memory-related problems, and high risk of malnutrition were associated with non-operative treatment. Conversely, the ability to walk independently was associated with surgery. The multivariable analysis resulted in two models. The ‘objective’ model (Nagelkerke R2 53.2%) included female sex (OR 0.19, 95% CI 0.05–0.76), nursing home residency (OR 3.23, 95% CI 0.98–10.62), high risk of pressure ulcers (OR 6.85, 95% CI 1.86–25.18) and higher ASA classification (OR for ASA IV 11.63, 95% CI 1.48–91.23). The ‘subjective’ model (Nagelkerke R2 38.1%) incorporated patient preferences (OR 0.22, 95% CI 0.07–0.66), baseline mobility (OR 0.20, 95% CI 0.08–0.52), and clinical assessment of nutritional status (OR 11.24, 95% CI 1.16–109.34). 30-day, 1-year, and 2-year mortality rates were 54.3%, 73.9%, and 87.0% for patients with non-operative treatment and 19.0%, 48.3%, and 72.4% for patients who underwent surgery, respectively. This study investigated the role of MDT discussions in the treatment of geriatric trauma patients, revealing that 44.2% of those discussed underwent non-operative treatment. This percentage is notably high, especially considering that these patients were generally less frail and more likely to be living at home, in contrast to similar studies.8, 10 Additionally, we studied factors as documented in MDT records. Surprisingly, patient preferences were documented in merely one-third of the cases, whereas other factors like comorbidity, baseline mobility, and cognitive function were considered more frequently. This suggests a gap in patient involvement and also that medical judgment prevailed, especially in situations with considerable surgical risk or when the need for surgery was already established. Our findings highlight that decision-making is influenced by both objective clinical data and subjective evaluations, emphasizing the need for a holistic approach. Furthermore, we demonstrated the reliability of electronic patient data as source for investigating these factors, supporting their use in research settings. Our study's limitations include a small sample size and a Dutch setting, potentially limiting its broader applicability. The absence of comprehensive data regarding care needs, pain control, and complications due to significant diagnostic bias, as patients treated conservatively had much shorter hospital stays, resulted in considerable post-discharge data gaps. Future studies should, therefore, focus on long-term care needs, nursing home admission rates, pain management effectiveness, and the experiences of families and caregivers in non-operative care scenarios. In conclusion, in this observational study, 44.2% of patients with hip fractures discussed in surgical decision-making MDT meetings received non-operative treatment. Our research sheds light on the complex decision-making process for geriatric trauma patients, emphasizing the need for a holistic approach to care. Future research could incorporate these decision-making factors into clinical aids to enhance patient care. Study conception and design: Vleeshouwers, Faut, Brouns, Spaetgens. Acquisition of data: Vleeshouwers, Faut, van Leendert, Vandenberghe, van der Hooft, Pijls, Göbbels, Saadan, Brouns, Spaetgens. Analysis and interpretation of data: Vleeshouwers, Faut, Sipers, Brüggemann, Brouns, Spaetgens. All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. The authors have declared no conflicts of interest. No funding was received for this work. Supplementary Table S1. Factors discussed in multidisciplinary team meeting impacting the decision and interobserver agreement statistics. 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