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Original Investigation | SURGICAL CARE OF THE AGING POPULATION

Patterns of Injury, Outcomes, and Predictors of In-Hospital and 1-Year Mortality in Nonagenarian and Centenarian Trauma Patients ONLINE FIRST

John O. Hwabejire, MD, MPH1,2; Haytham M. A. Kaafarani, MD, MPH1,2; Jarone Lee, MD, MPH1,2; Daniel D. Yeh, MD1,2; Peter Fagenholz, MD1,2; David R. King, MD1,2; Marc A. de Moya, MD1,2; George C. Velmahos, MD, PhD1,2
[+] Author Affiliations
1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston
2Harvard Medical School, Boston, Massachusetts
JAMA Surg. Published online August 13, 2014. doi:10.1001/jamasurg.2014.473
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Importance  With the dramatic growth in the very old population and their concomitant heightened exposure to traumatic injury, the trauma burden among this patient population is estimated to be exponentially increasing.

Objective  To determine the clinical outcomes and predictors of in-hospital and 1-year mortality in nonagenarian and centenarian trauma patients (NCTPs).

Design, Setting, and Participants  All patients 90 years or older admitted to a level 1 academic trauma center between January 1, 2006, and December 31, 2010, with a primary diagnosis of trauma were included. Standard trauma registry data variables were supplemented by systematic medical record review. Cumulative mortality rates at 1, 3, 6, and 12 months after discharge were investigated using the Social Security Death Index. Univariate and multivariable analyses were performed to identify the predictors of in-hospital and 1-year postdischarge cumulative mortalities.

Main Outcomes and Measures  Length of hospital stay, in-hospital mortality, and cumulative mortalities at 1, 3, 6, and 12 months after discharge.

Results  Four hundred seventy-four NCTPs were included; 71.7% were female, and a fall was the predominant mechanism of injury (96.4%). The mean patient age was 93 years, the mean Injury Severity Score was 12, and the mean number of comorbidities per patient was 4.4. The in-hospital mortality was 9.5% but cumulatively escalated at 1, 3, 6, and 12 months after discharge to 18.5%, 26.4%, 31.3%, and 40.5%, respectively. Independent predictors of in-hospital mortality were the Injury Severity Score (odds ratio [OR], 1.09; 95% CI, 1.02-1.16; P = .01), mechanical ventilation (OR, 6.23; 95% CI, 1.42-27.27; P = .02), and cervical spine injury (OR, 4.37; 95% CI, 1.41-13.50; P = .01). Independent predictors of cumulative 1-year mortality were head injury (OR, 2.65; 95% CI, 1.24-5.67; P = .03) and length of hospital stay (OR, 1.06; 95% CI, 1.02-1.11; P = .005). Cumulative 1-year mortality in NCTPs with a head injury was 51.1% and increased to 73.2% if the Injury Severity Score was 25 or higher and to 78.7% if mechanical ventilation was required. Most NCTPs required rehabilitation; only 8.9% were discharged to home.

Conclusions and Relevance  Despite low in-hospital mortality, the cumulative mortality rate among NCTPs at 1 year after discharge is significant, particularly in the presence of head injury, spine injury, mechanical ventilation, high injury severity, or prolonged length of hospital stay. These considerations can help guide clinical decisions and family discussions.

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Cumulative Mortality Rates

The in-hospital mortality was 9.5%. Cumulative mortality rates at 1, 3, 6, and 12 months after discharge were 18.5%, 26.4%, 31.3%, and 40.5%, respectively.

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