Abstract
Objectives:
Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes.
Methods:
This retrospective analysis included patients ≥ 45 years old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016–2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45–64 and 65+. Outcomes included ventilator-associated pneumonia (VAP), unplanned endotracheal intubation, acute respiratory distress syndrome (ARDS), in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, BMI, ISS, flail chest, COPD, CHF, and smoking.
Results:
2,839 patients aged 45–64 and 1,828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with VAP, unplanned intubation, ARDS, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (p > 0.05). Black (odds ratio (OR) 0.67; 95% confidence interval (CI): 0.59, 0.77; p < 0.001), Hispanic (OR 0.80; 95% CI: 0.71, 0.91; p < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76, 0.95; p = 0.005) patients were less likely to receive SSRF.
Conclusion:
No differences in clinical outcomes were measured between adults aged 45–64 and ≥ 65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.
Keywords: Rib fracture, surgical stabilization of rib fractures, ageism, surgical disparities
Introduction
Rib fractures are a significant source of morbidity and mortality among trauma patients. Roughly 10% of all trauma patients present with at least one rib fracture, and 49.5% of patients with rib fractures are admitted to the intensive care unit.1,2 Older adults are considered a particularly high-risk population for sustaining rib fractures and developing post-fracture complications, including respiratory failure and death.3 For patients over 65 years of age, the mortality rate increases by 19% for each subsequent rib fracture, and the risk of pneumonia increases by 27% relative to their younger counterparts.4 However, more recent studies have shown that significant rises in complication rates begin earlier – at age 45 rather than 65.5–8 These findings are indicative of the urgency and necessity of improved treatment options for adult patients with rib fractures, especially for older adult patients who have a higher risk of serious morbidity and mortality.9
Substantial progress in research and utilization of the surgical stabilization of rib fractures (SSRF) has prompted renewed interest in the operative treatment of rib fractures.10 In past clinical practices, SSRF was reserved for severe cases of flail chest and for patients who cannot be extubated.11–15 More recent research has supported SSRF as a safe and effective treatment for rib fractures, leading to fewer complications, including ventilator-associated pneumonia and acute lung injury, and decreased hospital length of stay.16–19 However, despite multiple randomized control trials, the literature on SSRF outcomes in non-flail patients remains mixed.20–22 Nonetheless, the benefits of SSRF have been exhibited when performed early, especially on patients with multiple or overlying fractures.23
Despite the surge in studies demonstrating positive outcomes for SSRF, its use and benefits may not be equally allotted to all age groups, races, and socioeconomic statuses. Disparities in thoracic trauma outcomes have been well-recorded across race, ethnicity, and insurance status.24–28 Black, Hispanic, and uninsured patients have been shown to be less likely to receive SSRF in 2015, but no studies have yet to examine this trend across more recent years.29 Older patients are also less likely to receive SSRF despite having an increased risk of complications and evidence that operative management may be associated with improved outcomes.30,31 Overall, existing literature indicates that inequities exist in the use of SSRF and that conservative management of adult patients may not provide the adequate care needed to optimize outcomes. To investigate whether disparities persist in the use of SSRF and its associated outcomes, this study primarily aimed to assess ageism in the use of SSRF – specifically, if clinical outcomes after SSRF differ between older adults and the general adult population. Secondary aims investigated additional disparities in the use of SSRF, including if the use of SSRF continues to vary by race, ethnicity, and socioeconomic status and if the timing of SSRF varies by race, ethnicity, socioeconomic status, and age.
Methods
Study Design and Setting
This retrospective cohort study collected data from the American College of Surgeon’s Trauma Quality Improvement Program (TQIP). TQIP collects deidentified patient information from approximately 900 institutions in the United States and controls for variability among establishments with risk-adjusted benchmarking. Data collection and analysis were conducted in agreement with the TQIP data use agreement, and the study was granted Institutional Review Board approval at Duke University Hospital.
Selection of Participants
Using the TQIP database, we selected patients aged 45 years and older diagnosed with a rib fracture from 2016 to 2020 to include in our study. Patients who received SSRF and those with rib fractures were identified using ICD-10 Procedure Coding System (PCS) and Clinical Modification (CM) codes, respectively. The age cutoff was selected to reflect how mortality from rib fracture significantly increases at age 45.5 To control for severity and polytrauma, individuals with an Abbreviated Injury Scale (AIS) score for thorax ≥ 3 were included, while patients with AIS > 3 for head, abdomen, and pelvis, AIS of 6 in thorax, and/or arrival to the ED but not admitted to the hospital were excluded. We excluded ED death and no mortality following admission. To ensure sufficient data was provided by an institution in TQIP, centers that did not report or reported 0 cases of deep vein thrombosis (DVT) and pneumonia (PNA) in that year of data collection were excluded from the analysis. In other words, if a center reported DVT and PNA in 2017 but not 2016, data from that center in 2017 were included, while data from 2016 were excluded.
Measures
The following variables were collected from TQIP. Patient information of interest included age, race, ethnicity, and insurance payer status. Race (White, Black, Other, and Unknown) was either self-reported or identified by a family member. Ethnicity was classified into Hispanic, non-Hispanic, and Unknown. Payer status was categorized into self-pay vs insured (excluding unknown). Comorbidities and complications (flail chest, COPD, CHF, and DVT), as well as emergency and hospital discharge disposition, were collected as potential covariates. Injuries were grouped based on location of injury and severity, defined by AIS, along with ISS scores.
Outcomes
The primary outcome assessed by this study was the development of ventilator-associated pneumonia (VAP) among patients who received SSRF. Secondary outcomes included diagnosis of acute respiratory distress syndrome (ARDS), in-hospital mortality, unplanned endotracheal intubation (i.e., hospital complication), time spent in the hospital/ED before the procedure, and failure to rescue (FTR). FTR was evaluated in two different ways: 1.) failure to rescue after pulmonary complications and 2.) failure to rescue after any major complications. Pulmonary complications were adapted from previous definitions in the literature on thoracic surgery, including VAP, unplanned intubation, and ARDS. Major complications were selected from those that contribute the most to trauma mortality, which included the aforementioned pulmonary ones, in addition to severe sepsis, pulmonary embolism, acute kidney injury, or a cardiovascular event (i.e., cardiac arrest, myocardial infarction).32,33 FTR after pulmonary complications were separately assessed due to the prevalence of respiratory impairment in patients with rib fractures. All outcomes were defined using ICD-10 codes and Participant User Data Files (PUF), which are de-identified patient-level data provided in TQIP.
Analysis of Demographic and Clinical Differences Between Patients with and without SSRF
Median (Q1, Q3) and frequency (percent) of demographic and injury characteristics were calculated for adults 45–64 years of age and older adults 65 years of age and older. We first separated the two groups as distinct cohorts and, within these cohorts, further subdivided into those who did and did not receive SSRF.
Analyses on the Association between SSRF and Demographic Characteristics (Race, Ethnicity, and Payer Status)
A logistic regression model was used to assess the association between demographic characteristics (race, ethnicity, and payer status) and use of SSRF while controlling for age, gender, BMI, ISS, flail chest, and comorbidities.
Analyses on Outcomes of SSRF in Adult Patients (45–64 Years) vs Older Adult Patients (65+ Years)
A logistic regression model, controlling for age, gender, BMI, ISS, flail chest, and comorbidities, was fit to assess the association between SSRF, age, and SSRF*age. If the overall interaction effect (SSRF*age) was not significant, then a main effect model excluding the interaction term was fit to assess the association of SSRF with each outcome.
Analysis on the Timing of SSRF and its Association with Clinical Outcomes Based on Age, Race, Ethnicity, and Insurance
Using restricted cubic splines with 4 knots, the functional form of time to SSRF was revealed to be linear. Thus, for each outcome, a logistic regression model was fit with interaction term between the timing of SSRF and age. Due to low event rates, the model for ARDS, in-hospital mortality, and FTR were fit with time to SSRF, age, ISS, flail chest, COPD, CHF, and smoking as covariates. If the overall interaction effect (time to SSRF*age) was not significant, then a main effect model excluding the interaction term was fit to assess the association of time to SSRF with each outcome. We implemented the SAS macro by Desquilbet and Mariotti (2010) for the restricted cubic splines analysis.34 After a functional form was determined, subsequent were standard procedures that exist in SAS. Statistical analyses were conducted using R version 4.3.2 (R Core Team, Vienna, Austria), and the threshold for statistical significance was set at p < 0.05.
Results
Cohort Characteristics
From hospitals and centers contributing to TQIP, 208,329 patients had a rib fracture between 2016 and 2020, and 4,667 patients received SSRF. 8.8% of patients with a severe injury (i.e., AIS chest score of 4) underwent SSRF compared to 1.9% of patients with a serious injury (i.e., AIS chest score of 3). The median ISS of patients with and without SSRF were both 14 (Q1: 10, Q3: 17). A history of smoking and other comorbidities (COPD, CHF, flail chest) were more prevalent among patients who underwent SSRF, which are further described in Table 1.
Table 1:
Demographics, Comorbidities and Injury Characteristics Among Adults Ages 45 and Older with Rib Fractures by Surgical Stabilization of Rib Fractures (SSRF)
| No SSRF (N=203,662) | SSRF (N=4,667) | Total (N=208,329) | |
|---|---|---|---|
| Age (years) | |||
| Median (Interquartile Range) | 64 (56.0, 75.0) | 61 (54.0, 70.0) | 64 (56.0, 75.0) |
| Gender | |||
| Female | 124,265 (61.0%) | 3,261 (69.9%) | 127,526 (61.2%) |
| Male | 79,382 (39.0%) | 1,406 (30.1%) | 80,788 (38.8%) |
| Race | |||
| American Indian | 1,118 (0.6%) | 42 (0.9%) | 1,160 (0.6%) |
| Asian | 4,095 (2.0%) | 79 (1.7%) | 4,174 (2.0%) |
| Black or African American | 15,511 (7.7%) | 273 (6.0%) | 15,784 (7.7%) |
| Native Hawaiian or Other Pacific Islander | 392 (0.2%) | 7 (0.2%) | 399 (0.2%) |
| White | 166,823 (83.2%) | 3,934 (85.7%) | 170,757 (83.2%) |
| Other Race | 12,592 (6.3%) | 253 (5.5%) | 12,845 (6.3%) |
| Unknown | 3,131 (1.5%) | 79 (1.7%) | 3,210 (1.5%) |
| Ethnicity | |||
| Hispanic | 15,582 (7.7%) | 313 (6.7%) | 15,895 (7.6%) |
| Not Hispanic | 180,380 (88.6%) | 4,180 (89.6%) | 184,560 (88.6%) |
| Unknown | 7,700 (3.8%) | 174 (3.7%) | 7,874 (3.8%) |
| Insurance | |||
| Medicaid | 18,729 (9.2%) | 409 (8.8%) | 19,138 (9.2%) |
| Medicare | 78,716 (38.7%) | 1,430 (30.6%) | 80,146 (38.5%) |
| Private/Commercial Insurance | 79,682 (39.1%) | 2,050 (43.9%) | 81,732 (39.2%) |
| Self-Pay | 11,980 (5.9%) | 327 (7.0%) | 12,307 (5.9%) |
| Other government | 4,382 (2.2%) | 127 (2.7%) | 4,509 (2.2%) |
| Other | 6,161 (3.0%) | 144 (3.1%) | 6,305 (3.0%) |
| Unknown | 4,012 (2.0%) | 180 (3.9%) | 4,192 (2.0%) |
| Body mass index | |||
| Median (Interquartile Range) | 27.3 (23.9, 31.6) | 28.6 (25.1, 32.9) | 27.4 (24.0, 31.6) |
| Injury severity score | |||
| Median (Interquartile Range) | 14 (10.0, 17.0) | 14 (10.0, 21.0) | 14 (10.0, 17.0) |
| AIS chest | |||
| 3 - Serious injury | 192,468 (94.5%) | 3,725 (79.8%) | 196,193 (94.2%) |
| 4 - Severe injury | 9,054 (4.4%) | 799 (17.1%) | 9,853 (4.7%) |
| 5 - Critical injury | 2,140 (1.1%) | 143 (3.1%) | 2,283 (1.1%) |
| Comorbidities | |||
| One or more comorbidities | 173,223 (85.1%) | 3,955 (84.7%) | 177,178 (85.0%) |
| Chronic obstructive pulmonary disease | 87,250 (42.8%) | 2,275 (48.7%) | 89,525 (43.0%) |
| Congestive heart failure | 85,414 (41.9%) | 2,267 (48.6%) | 87,681 (42.1%) |
| Flail chest | 2,849 (1.4%) | 753 (16.1%) | 3,602 (1.7%) |
| History of smoking | 90,463 (44.4%) | 2,299 (49.3%) | 92,762 (44.5%) |
| Time to SSRF (Days) | |||
| Median (Interquartile Range) | 4 (3.0, 6.0) | 4 (3.0, 6.0) | |
| Year | |||
| 2016 | 31,490 (15.5%) | 484 (10.4%) | 31,974 (15.3%) |
| 2017 | 46,438 (22.8%) | 956 (20.5%) | 47,394 (22.7%) |
| 2018 | 39,263 (19.3%) | 863 (18.5%) | 40,126 (19.3%) |
| 2019 | 43,769 (21.5%) | 1,075 (23.0%) | 44,844 (21.5%) |
| 2020 | 42,702 (21.0%) | 1,289 (27.6%) | 43,991 (21.1%) |
Legend:
Data was obtained from the Trauma Quality Improvement Program from 2016–2020.
Association between SSRF and Demographic Characteristics (Race, Ethnicity, and Payer Status)
Race, ethnicity, and insurance payer status were significantly associated with the use of SSRF (Table 2). Black patients were one-third less likely to receive SSRF than White patients (odds ratio = OR 0.67; 95% confidence interval = CI [0.59, 0.77]; p < 0.001). Though proportionally fewer Asian patients received SSRF than White patients, the association was not significant (OR 0.84; 95% CI [0.67, 1.05]; p = 0.125). Hispanic or Latino patients were 20% less likely to receive SSRF (OR 0.80; 95% CI [0.71, 0.91]; p < 0.001). Patients with Medicaid were 15% less likely to receive SSRF than private/commercial insurance (OR 0.85; 95% CI [0.76, 0.95]; p = 0.005).
Table 2.
Odds of Receiving Surgical Stabilization of Rib Fractures (SSRF) by Race, Ethnicity, and Socioeconomic Status
| Variable | Odds Ratio (95% CI) | p-value |
|---|---|---|
| Race | <0.001* | |
| Asian vs White | 0.84 (0.67, 1.05) | 0.125 |
| Black or African America vs White | 0.67 (0.59, 0.77) | <0.001 |
| Other vs White | 0.95 (0.84, 1.08) | 0.440 |
| Unknown vs White | 1.05 (0.82, 1.34) | 0.712 |
| Ethnicity | 0.003* | |
| Hispanic or Latino vs Not Hispanic or Latino | 0.80 (0.71, 0.91) | <0.001 |
| Unknown vs Not Hispanic or Latino | 0.94 (0.80, 1.12) | 0.492 |
| Insurance | <0.001* | |
| Medicaid vs Private/Commercial Insurance | 0.85 (0.76, 0.95) | 0.005 |
| Medicare vs Private/Commercial Insurance | 0.95 (0.87, 1.03) | 0.204 |
| Self-Pay vs Private/Commercial Insurance | 1.09 (0.96, 1.23) | 0.175 |
| Other vs Private/Commercial Insurance | 0.96 (0.80, 1.14) | 0.615 |
| Other Government vs Private/Commercial Insurance | 1.14 (0.94, 1.37) | 0.182 |
| Unknown vs Private/Commercial Insurance | 1.91 (1.63, 2.25) | <0.001 |
Legend:
p-value from Type 3 test.
This model controlled for age, gender, BMI, missing indicator for BMI, ISS, flail chest, and comorbidities including COPD, CHF, smoking.
Data was obtained from the Trauma Quality Improvement Program from 2016–2020.
Outcomes of SSRF in Adult Patients (45–64 Years) vs Older Adult Patients (65+ Years)
The association between SSRF and each outcome did not vary between adult and older adult patients (VAP: p = 0.661; unplanned intubation: p = 0.478; ARDS = 0.480; in-hospital mortality: p = 0.936; FTR after a major complication: p = 0.256; FTR after a respiratory complication: p = 0.310). Therefore, a main effect model without interaction variable between SSRF and age group was fit to assess outcomes of SSRF in the general adult population. Covariates of age, gender, race, ethnicity, insurance, BMI, ISS, flail chest, COPD, CHF, and smoking remained in the model as these factors varied significantly between patients who did and did not receive SSRF. Patients receiving SSRF had higher odds of VAP (OR 2.33; 95% CI [1.93, 2.81], p < 0.001), unplanned intubation (OR 2.56; 95% CI [2.29, 2.87], p < 0.001), and ARDS (OR 1.39; 95% CI [1.06, 1.83]; p = 0.018) but were approximately half as likely to die in the hospital (OR 0.47; 95% CI [038, 0.49]; p < 0.001) and had lower odds of FTR after a major (OR 0.37; 95% CI [0.28, 0.49] p < 0.001) or respiratory (OR 0.41; 95% CI [0.31, 0.55], p < 0.001) complication. All outcomes are listed in Table 3.
Table 3.
Odds and Outcomes of Receiving Surgical Stabilization of Rib Fractures (SSRF) for Adults 45+ Years of Age
| SSRF vs no SSRF | |||
|---|---|---|---|
| Outcomes | Interaction p-value (SSRF*age group1) | OR (95% CI) | P |
| Ventilator-associated pneumonia | 0.661 | 2.33 (1.93, 2.81) | <0.001 |
| Unplanned intubation | 0.478 | 2.56 (2.29, 2.87) | <0.001 |
| Acute respiratory distress syndrome | 0.480 | 1.39 (1.06, 1.83) | 0.018 |
| In-hospital mortality | 0.936 | 0.47 (0.38, 0.57) | <0.001 |
| Failure to rescue v1 (after a major complication2) | 0.256 | 0.37 (0.28, 0.49) | <0.001 |
| Failure to rescue v2 (after having ventilator-assisted pneumonia, unplanned intubation, or acute respiratory distress syndrome) | 0.310 | 0.41 (0.31, 0.55) | <0.001 |
Legend:
The variable, age group, compared adults ages 45–64 with adults ages 65+.
Major complications included severe sepsis, ventilator-assisted pneumonia, pulmonary embolism, acute respiratory distress syndrome, acute kidney injury, or a cardiovascular event (i.e. cardiac arrest, myocardial infarction).
All models controlled for age, gender, race, ethnicity, insurance, BMI, missing indicator for BMI, ISS, flail chest, and comorbidities including COPD, CHF, smoking.
Data was obtained from Trauma Quality Improvement Program from 2016–2020
Timing of SSRF and its Association with Clinical Outcomes Based on Age, Race, Ethnicity, and Insurance
No significant interaction was observed between the timing of SSRF and age group, race, ethnicity, or insurance (interaction p-values > 0.05; listed in Table 4). One additional day to SSRF from admission (i.e., waiting one more day to perform SSRF) was associated with higher odds of having VAP (OR 1.07; 95% CI [1.03, 1.11]; p < 0.001) and unplanned intubation (OR 1.10; 95% CI [1.08, 1.13]; p < 0.001) as well as lower odds of FTR after a major (OR 0.90; 95% CI [0.83, 0.97]; p = 0.007) or respiratory (OR 0.87; 95% CI [0.78, 0.96]; p < 0.006) complication. No significant association was observed between timing and in-hospital mortality (OR 0.99; 95% CI [0.93, 1.04]; p = 0.601).
Table 4.
Timing of Rib Fixation and its Impact on Clinical Outcomes for Adults 45+ Years of Age
| For one additional day to SSRF | |||
|---|---|---|---|
| Outcomes | Interaction p-value (days to SSRF*age group1) | OR (95% CI) | P |
| Ventilator-associated pneumonia1 | 0.389 | 1.07 (1.03, 1.11) | <0.001 |
| Unplanned intubation2 | 0.734 | 1.10 (1.08, 1.13) | <0.001 |
| Acute respiratory distress syndrome3 | 0.846 | 1.10 (1.05, 1.15) | <0.001 |
| In-hospital mortality3 | 0.512 | 0.99 (0.93, 1.04) | 0.601 |
| Failure to rescue v13 (after a major complication4) | 0.780 | 0.90 (0.83, 0.97) | 0.007 |
| Failure to rescue v23 (after having ventilator-assisted pneumonia, unplanned intubation, or acute respiratory distress syndrome) | 0.085 | 0.87 (0.78, 0.96) | 0.006 |
Legend:
The variable, age group, compared adults ages 45–64 with adults ages 65+.
Covariates included age, gender, race, ethnicity, insurance, BMI, missing indicator for BMI, ISS, flail chest, and comorbidities including COPD, CHF, smoking.
Due to low event rate, model included age, ISS, flail chest, and comorbidities including COPD, CHF, smoking.
Major complications included severe sepsis, ventilator-assisted pneumonia, pulmonary embolism, acute respiratory distress syndrome, acute kidney injury, or a cardiovascular event (i.e. cardiac arrest, myocardial infarction).
Data was obtained from Trauma Quality Improvement Program from 2016–2020.
Discussion
This is the first study to show that age does not confer a better prognosis post-SSRF; for patients selected to receive SSRF, older adults are not at higher risk of complications from the operation than younger adults. Adjusted analysis revealed that rates of VAP, ARDS, unplanned intubation, in-hospital mortality, and FTR after a respiratory or major complication were not significantly different between adults 65+ years of age and those aged 45–64 years old. Among adults who received SSRF, both adults 45–64 years old and those 65+ years of age were half as likely to die in the hospital than those in their respective age cohorts who did not receive SSRF. Further, age was not associated with the timing of rib fixation. The current study underscores the association between SSRF and improved outcomes for patients with rib fractures, including among those aged 65+ years - with appropriate patient selection, older age should not preclude patients from receiving SSRF.
Our results suggest that, among patients who receive SSRF, older adults are not at greater risk of developing complications than their younger counterparts. Studies have demonstrated that patients aged 65 and older are less likely to undergo surgical stabilization when compared to a younger population despite older age being a major risk factor for developing post-fracture complications.35–37 This discrepancy is suggestive of ageism in the use of SSRF – that is, that the decision to operate may be based, not on evidence-based factors of poorer outcomes, but rather a theoretical supposition of risks. A past study found that patients aged 65 and older who underwent SSRF had significantly lower odds of in-hospital mortality compared to those who underwent nonoperative management.31 Decreased bone density, muscle mass, and chest wall elasticity, combined with increased risk of falling in older individuals, might contribute to the severity of rib fractures in this population.15–18 However, despite their susceptibility to significant complications from rib fractures, patients over 70 years old have been found to be 8.6% less likely to undergo SSRF when compared to younger patients.31 Indeed, our data shows no significant difference in complication rates and mortality between adults aged 45–64 years old and 65 years of age and older. Consequently, our findings suggest that, in clinical practice, older age should not be the qualifying factor that precludes patients from receiving SSRF. Rather, ageist bias should be re-examined when considering whether an older adult patient should undergo SSRF, particularly if such a patient would have been operatively treated had they been younger.
Our results not only suggest that SSRF does not pose an increased risk for older patients, but also demonstrate that all patients older than 45 years of age who receive SSRF have lower odds of mortality and improved chances of surviving a post-operative complication. This study is congruent with previous literature on the safety of SSRF for the treatment of rib fractures.38–41 While nonoperative management focuses on pulmonary support and pain management, SSRF seeks to repair the thoracic cage to improve respiratory function and control pain, thus contributing to a shorter time to recovery and earlier return to work and leisure.32 For each additional rib fracture for patients over the age of 65, mortality rate increases by 19% and risk for pneumonia increases by 27%.11–15 Our study showed that adults receiving SSRF had higher odds of VAP, unplanned intubation, and ARDS, but were less likely to die in the hospital and had lower odds of FTR after either a major complication or respiratory complication. Notably, these odds did not vary between patients aged 45 to 64 and those 65 years of age and older. Given the study’s retrospective design and use of deidentified data, the timing of the complication, relative to the use of SSRF, was not determinable. Thus, the higher rates of VAP, unplanned intubation, and ARDS may be indicative of SSRF being used for rescue rather than prevention of adverse outcomes. The higher rates of complications could also be due to the invasiveness associated with surgical management. ARDS, in particular, may be more likely in patients undergoing SSRF of 3 or more ribs.42 However, factors that increase inflammatory mediators responsible for ARDS include surgical intervention, tissue trauma, and anesthesia, which may not be unique to SSRF.43 Further, studies have found no significant difference in rates of pneumonia or other respiratory complications between SSRF and conservative treatment.36–39 When considering the serious risk imposed by rib fractures on adult patients, particularly older adults, a nearly 50% reduction of in-hospital mortality in those who underwent SSRF demonstrates the benefit of this approach. Therefore, while SSRF may decrease morbidity and mortality, qualifying criteria could be further explored regardless of age group. The potential tradeoff between improved mortality and increased risk of respiratory complications underscores the need for more data on functional outcomes and post-discharge destinations for older adults who receive operative treatment.
In addition to the development of complications, failure to rescue (FTR) may be used to help understand morbidity and mortality among patients. Indeed, as FTR specifically measures mortality after a complication, FTR may be a more precise metric of surgical outcomes and quality of care.44,45 Past evidence demonstrated that sepsis, pneumonia, and ARDS may significantly contribute to increased rates of FTR and patient mortality.33 In this study, SSRF showed decreased rates of FTR for the general adult population for both respiratory and non-respiratory complications. Given that receiving SSRF correlated with higher odds of pulmonary complications, the decreased mortality associated with SSRF relative to conservative management may be attributed to reductions in FTR after the procedure. Thus, our study suggests that, when assessing the association between operative treatment and patient outcomes, FTR should be measured alongside the incidence of complications.
Limitations
As a retrospective cohort study, sampling bias and errors are limiting factors. Specifically, analyses compared adults ages 45–64 with those ages 65 and older, selected to undergo SSRF. Thus, limiting the conclusions that can be made about the entire older adult population as the TQIP database does not enable distinctions between older adults deemed not appropriate surgical candidates versus those who did not receive SSRF due to their age. Though the study attempted to address this possible distinction by controlling for medical comorbidities and socioeconomic factors, selection of the cohort remains a serious limitation due to the study’s design. Similarly, the reliance on accurate coding of rib fractures, surgical management, and associated complications is a limitation of the TQIP dataset. In addition, hospital characteristics were not collected and, thus, not controlled for in our analysis, which may have shown differences in the utilization of SSRF, depending on the size and teaching status of the hospital. Furthermore, the use of codes prevented assessment of the time in which SSRF was performed in relation to the clinical status of the patient. In other words, whether the patients received SSRF early to improve prognosis or underwent surgery later due to the development of complications was not measurable in this retrospective study. Additionally, the demographics represented here are similar to those in TQIP but may not directly translate to larger populations. We were also limited to single-system complications and were unable to measure complications requiring multiorgan support, such as respiratory and cardiopulmonary interventions. Lastly, given the deidentified nature of TQIP, we are unable to examine the long-term morbidity and mortality of SSRF in older adults. While SSRF was associated with a decrease in in-hospital morbidity and mortality for both age groups, the impact on older adults post-discharge was not explored.
Conclusion
This study reveals that older age is not associated with a worse prognosis of SSRF among adults with rib fractures. Our analysis suggests that surgical intervention does not confer a greater risk of deleterious outcomes, including ventilator-associated pneumonia and in-hospital mortality, for older adults relative to their younger counterparts. In addition, each additional day to SSRF is associated with increased odds of respiratory complications and death with no substantial correlation to younger or older age. With no significant difference in in-hospital morbidity and mortality among adults aged 45–64 years old and adults aged 65 years old and older, surgical stabilization should be considered regardless of age.
Supplementary Material
Supplemental Fig. 1: CONSORT Diagram
Funding:
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
This manuscript’s abstract was accepted to the 2024 ASC Meeting.
Footnotes
Disclosure: Dr. Agarwal is an Associate Editor for the Journal of Surgical Research; as such, he was excluded from the entire peer-review and editorial process for this manuscript.
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Associated Data
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Supplementary Materials
Supplemental Fig. 1: CONSORT Diagram