Palliative Non-Operative Management in Geriatric Hip Fracture Patients: When Would Surgeons Abstain from Surgery?

For hip fracture patients with a limited life expectancy, operative and palliative non-operative management (P-NOM) can yield similar quality of life outcomes. However, evidence on when to abstain from surgery is lacking. The aim of this study was to quantify the influence of patient characteristics on surgeons' decisions to recommend P-NOM. Dutch surgical residents and orthopaedic trauma surgeons were enrolled in a conjoint analysis and structured expert judgement (SEJ). The participants assessed 16 patient cases comprising 10 clinically relevant characteristics. For each case, they recommended either surgery or P-NOM and estimated the 30-day postoperative mortality risk. Treatment recommendations were analysed using Bayesian logistic regression, and perceived risks were pooled with equal and performance-based weights using Cooke's Classical Model. The conjoint analysis and SEJ were completed by 14 and 9 participants, respectively. Participants were more likely to recommend P-NOM to patients with metastatic carcinomas (OR: 4.42, CrI: 2.14-8.95), severe heart failure (OR: 4.05, CrI: 1.89-8.29), end-stage renal failure (OR: 3.54, CrI: 1.76-7.35) and dementia (OR: 3.35, CrI: 1.70-7.06). The patient receiving the most P-NOM recommendations (12/14) had a pooled perceived risk of 30-day mortality between 50.8 and 62.7%. Overall, comorbidities had the strongest influence on participants' decisions to recommend P-NOM. Nevertheless, practice variation and heterogeneity in risk perceptions were substantial. Hence, more decision support for considering P-NOM is needed.