Monthly Archives: July 2022

RICHMOND, Va. -- New moms receiving Medicaid assistance will now have their healthcare costs covered for a longer period of time.

Starting this month, Virginia Medicaid will expand from 60 days to 12 months of postpartum health coverage for enrollees.

Sara Cariano, a health policy analyst with Virginia Poverty Law Center, says the goal is to lower the maternal mortality rates in Virginia.

"A lot of women are still dying from pregnancy related complications after their coverage ends, so we want to get women in care, keep them in care, and not make them change health plans two months after having a baby," Cariano said.

This change applies those enrolled in FAMIS Moms and Medicaid for Pregnant Women.

"Medicaid and FAMIS cover a third of the births in Virginia, so this is really going to impact a lot of women, and a lot of these women previously, after 60 days, didnt have access to care because they didnt have coverage," Cariano said.

WTVR

According to the Virginia Department of Health, more than half of pregnancy-related deaths happen 43 days or more after the end of pregnancy. In Virginia, the mortality rate among Black mothers is more than two times higher than the mortality rate among white mothers.

Kenda Sutton-El, the Executive Director of Birth in Color RVA, works one-on-one with moms at higher risk.

"Theres always the stigma, especially when it comes to Black women, as soon as we go in there, the condition of our skin already puts us at a higher risk than other people," Sutton-El said. "One of the biggest concerns is that providers dont listen to what they have to say, or they dont feel comfortable telling their providers.

Non-English speakers and immigrants are also at higher risk of pregnancy-related health issues.

The folks who are the most vulnerable across the board who have the largest disparities are also most likely to not know about the coverage or a little nervous to enroll in it because they dont want it to interfere with immigration status or immigration proceedings," Cariano said.

WTVR

Dr. Tashima Lambert Giles, a board-certified OB/GYN with VCU Health, sees the impact of a lack of coverage first-hand.

"The truth is that a lot of our patients that are Medicaid have lower socioeconomic status. They have a lot more reasons to feel a lot more stressed, unsupported. They might have to get back to work a lot sooner than other moms," Dr. Lambert Giles said. "This might cause them to lose that access and lose the ability to recognize if theres something medically related thats going on, and not see a physician, because theyre continuing with normal life.

The expansion covers everything from regular check-ups, to substance abuse disorders, to postpartum depression care.

Dr. Lambert Giles said in her practice, she's seen more new mothers struggling with heart disease, underlying conditions left untreated, and mental health issues.

"I think Medicaid expansion allows us to tackle all of those things, but most importantly, getting preventative medicine to patients so that they overall patient is healthy, and we can get a community thats healthier," she said

Children born to Medicaid/FAMIS enrollees are entitled to 12 months of continuous coverage. Criteria and benefit details can be found here.

This is a developing story, so anyone with more information can email newstips@wtvr.com to send a tip.

Continued here:
What Medicaid expansion means for new moms in Virginia - CBS 6 News Richmond WTVR

After working as a registered nurse in hospital settings for several years, Lindsey Herndon became a board-certified Family Nurse Practitioner a few years ago, shifting toward a holistic practice to pair with western medicine.

Herndon worked in Oregon for the past few years at a family practice where she embraced preventative healthcare, which is where she came up with the idea to open her own mobile business to offer both telehealth and mobile visits to patients homes.

Teaming up with local nurses and a business professional, Herndon launched BusyBee IV Hydration and Wellness, a mobile healthcare company offering traditional services akin to an urgent care, intravenous (IV) therapies, vitamin shots and Botox.

Instead of working more towards fixing the problem as it happens, weve shifted toward preventative healthcare so with the idea of IV, hydration and mobile urgent care, were taking that holistic approach to bring to the patient in the comfort of their own home, Herndon said.

With services treating a variety of ailments, ranging from respiratory infections to skincare to hangover relief, Herndon and her business partner, Megan Scameheorn, and her crew of registered nurses, Liz Gidley, Amy Bottomley and Meghan Neufeld, also offer group packages.

The Hangover Helper IV drip has become one of the most popular therapies, providing 1,000 ML of fluid, B complexes, magnesium, manganese, copper and selenium.

Customers often book IV therapy parties for events like birthdays, bachelor and bachelorette parties as a group activity before or after long weekends.

Its a fun experience for everybody, Scameheorn said We had a client who booked us for a birthday party, and she wanted to make sure everybody got hydrated when they went back to work and got their hangover cure.

In addition to hangover relief, another popular IV drip is the Worker Bee, which is geared toward athletes recovering from strenuous training and contains fluids and a variety of vitamins and minerals. The therapy is designed to address muscle soreness, fatigue and enhance athletic performances.

Other IV therapies include the Myers Cocktail, the Thirsty Bee and the Beeautiful, each containing fluids, vitamins and minerals geared toward general wellness, hydration and skincare.

Herndon and Scameheorn are working with event organizers to potentially set up a booth at the Whitefish Marathon and The Last Best Ride.

In addition to IV drips, Busy Bee offers vitamin shots containing B vitamins, Vitamin D, antioxidants, biotin and a Skinny Shot that helps reduce sugar cravings.

This is a town where people work hard and play hard and they need to feel good in order to operate well, Herndon said. So we have a holistic approach of doing urgent care, IV hydration and even aesthetics We treat the individual from the inside out so they can function and do the things they love to do.

For more traditional services, Busy Bee offers telehealth and in-home treatment for gastrointestinal issues, respiratory infections, urinary tract infections, COVID testing and earwax removal.

I think its really exciting to have the opportunity to promote wellness in our community outside of the hospital setting, Neufeld said.

For more information, visit http://www.busybee-iv.com.

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Healthcare for the Busy Bee - Flathead Beacon

Connecticut has seen an upward trend in COVID-19 cases over the past few weeks. While it may be possible that this increase is due to the new Omicron subvariants BA.4 and BA.5, public health officials say that its too soon to tell.

Dr. Manisha Juthani, commissioner of Connecticuts public health department, said its unclear exactly how widely BA.4 and BA.5 are spreading in Connecticut or the degree to which the new subvariants are contributing to the states recent uptick in COVID-19 cases and test positivity rate.

Its hard to say that the slight rise that were seeing is related to (the subvariants) or not, she said. Are we seeing this rise because of that? It is possible. I just dont have enough conclusive evidence to say that its absolutely the reason why.

Juthani, who was previously an infectious disease specialist at Yale New Haven Health, said that while the states COVID-19 numbers are still lower than they were this spring, the upward trend is increasingly hard to deny.

I dont want to sound the alarm every few weeks and then people start tuning out any sort of alarms, she said. But what I can say is that we are going in that direction.

Connecticut, like every other U.S. state, does not determine the variant of each positive case of coronavirus. Instead, the state Department of Public Halth, and Centers for Disease Control and Prevention, work with scientists, universities, hospitals and diagnostic labs to collect representative samples of positive tests for variant determination. These results are used to generate prevalence models to help public health officials estimate which variants predominate in states and across regions.

Yale New Havens Clinical Virology Lab, which mostly tracks outpatient samples from Fairfield, New Haven and New London counties, indicates that new cases are being driven by variants BA.2, BA.4 and BA.5. Regionally, the CDC estimates that the majority (roughly 42%) of new cases in New England are caused by BA.5.

According to Connecticuts public health department, new cases are up statewide with higher concentrations in the high population corridor between Stamford, New Haven and Hartford. This is despite overall higher vaccination rates in those areas.

Hospital utilization is up in the same area according to the federal Department of Health and Human Services. This upward trend can be seen across New England and New York. Every New England state but Vermont has over 70% hospital utilization. Connecticut is in the middle portion of the pack at 75% utilization. Rhode Island leads at 91%.

BA.5 has been reported to be more transmissible and immune evasive than previous strains of the coronavirus. Several studies have demonstrated that both BA.4 and BA.5 are more able to escape antibodies than previous variants. This is true for monoclonal antibody treatments, antibodies from prior infection and antibodies from vaccination.

Because of this immune evasion reports are emerging of more rapid reinfections than before. A CDC study documented ten cases of reinfection within 90 days of prior infection with the Delta variant across four states.

There have been a series of variants over time that have shared a couple characteristics, said Mark Adams deputy director at The Jackson Laboratory for Genomic Medicine. One is increased transmissibility ... but increasingly they seem to be driven by the ability to escape prior immune protection from SARS-COV-2.

The upshot is that even though this variant is more infectious it is not clear that it causes more severe or unusual infections. A large-scale study from Qatar indicates that vaccination is still extremely (97%) effective at preventing the worst outcomes even if vaccinated people still get sick.

It can infect people who have been previously infected but they tend to get a very mild infection, said Dr. William Schaffner, a professor of preventative medicine at Vanderbilt University Medical Center.

While some reports have emerged about unusual symptoms, such as viral meningitis, its not clear that this is a function of the new strain or a function of more cases increasing the likelihood of documenting rare complications.

We have heard, anecdotally, stories of a variety of symptoms (and recurrent infections) said Schaffner. But it isnt clear if its long symptoms or relapse or recurrent infection.

Its also not clear yet whether this wave of BA.4/5 will cause hospital capacity issues locally like it did in Portugal earlier in the spring. Transmission, severe infection and hospital use are complicated to predict.

Its really hard to predict the number of infections and the number of hospitalizations, said Adams. He encouraged people to get boosted if they could.

Its a real benefit. All the studies show that vaccination and boosting reduce the severity of disease, said Adams. The difference might be smaller (with the new variants) but its not going to be nothing.

See the article here:
The COVID BA.4 and BA.5 subvariants are highly transmissible. Here's what else people in CT need to know. - CT Insider

The NHS plans to use drones to fly chemotherapy drugs to cancer patients in England to avoid the need for long journeys to collect them.

The devices will transport doses from Portsmouth to the Isle of Wight in a trial that, if successful, will lead to drones being used for similar drops elsewhere.

They will take 30 minutes to travel across the Solent, which will save patients on the island a three to four-hour round trip by ferry or hovercraft.

On Tuesday, Amanda Pritchard, NHS Englands chief executive, unveiled the move to help mark the 74th anniversary of the health services creation by the postwar Labour government.

Delivering chemo by drone is another extraordinary development for cancer patients and shows how the NHS will stop at nothing to ensure people get the treatment they need as promptly as possible, while also cutting costs and carbon emissions, she said.

The first drone deliveries will start shortly, NHS England said, subject to the outcome of the last of a series of test flights on Tuesday.

It plans to use the drones electrical vertical takeoff and landing aircraft to collect the medications from the Queen Alexandra hospital in Portsmouth and fly them to St Marys hospital on the Isle of Wight, where staff will collect and distribute them.

The drones weigh 85kg, have a wingspan of 5 metres and can carry up to 20kg. The scheme is the result of a partnership between NHS England and the technology company Apian.

This project marks a very important first step in the construction of a network of drone corridors connecting hospitals, pathology labs, GP surgeries, care homes and pharmacies up and down the country, said Alexander Trewby, Apians chief executive.

If the flights prove successful it will be much more convenient for the majority of cancer patients on the Isle of Wight who now have to travel to the mainland to receive their drugs.

Darren Cattell, the chief executive of the Isle of Wight NHS trust, stressed that we are still at a relatively early stage of drone use in healthcare but that drone could have radical and positive implications for both the NHS and for patients across the UK as well as the Isle of Wight.

Sajid Javid, the health secretary, said: I want England to become a world leader in cancer care and using the latest technology to deliver chemo by drone means patients will have quicker, fairer access to treatment no matter where they live.

Meanwhile, a study has found that reinviting patients every year to be screened for bowel cancer the UKs second biggest cancer killer could speed up diagnosis and save lives.

Although the proportion of people taking up the NHSs invitation to get screened has risen to 67%, bowel cancer has the lowest participation rate of all the health services screening programmes.

New research by Sheffield University showed that sending people a new home testing kit every year until they return one could prompt 13.6% more people to do so.

The study was funded by Cancer Research UK (CRUK) and is published in the journal Preventative Medicine.

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Michelle Mitchell, CRUKs chief executive, said: Screening is an effective way of catching cancer early and saving lives, but not everyone engages equally, and this contributes to health inequalities across the UK.

This study shows that sending yearly test kits to those who dont complete them could help close this gap and save lives.

The test used, the faecal immunochemical test, better known as the FIT test, looks for traces of blood in someones faeces. At the moment everyone in England aged 60-74 who is registered with a GP is sent one every two years. However, the government has pledged to expand the programme to 50- to 59-year-olds and the NHS has begun inviting 56 and 58-year-olds for screening.

Genevieve Edwards, the chief executive of Bowel Cancer UK, said: We know that once someone has taken part in bowel cancer screening, theyre more likely to do so again. So it will also be vital to increase investment in endoscopy and pathology staff and equipment, to match an increase in demand for prompt follow-up tests.

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NHS to test using drones to fly chemotherapy drugs to Isle of Wight - The Guardian

Background

Smoking, obesity, and being below a healthy body weight are known to increase all-cause mortality rates and are considered modifiable risk factors. The purpose of this study is to assess whether adding these risk factors to a validated geriatric inpatient mortality risk tool will improve the predictive capacity for hip fracture patients. We hypothesize that the predictive capacity of the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool will improve.

Between October 2014 and August 2021, 2,421 patients >55-years-old treated for hip fractures caused by low-energy mechanisms were analyzed for demographics, injury details, hospital quality measures, and mortality. Smoking status was recorded as a current every-day smoker, former smoker, or never smoker.Smokers (current and former) were compared to non-smokers (never smokers).Body mass index (BMI) was defined as underweight (<18.5 kg/m2), healthy weight (18.5-24.9 kg/m2), overweight (25.0-24.9 kg/m2), or obese (>30 kg/m2). The baseline STTGMA tool for hip fractures (STTGMAHIP_FX_SCORE) was modified to include patients BMI and smoking status (STTGMA_MODIFIABLE), and new mortality risk scores were calculated. Each models predictive ability was compared using DeLongs test by analyzing the area under the receiver operating curves (AUROCs). Comparative analyses were conducted on each risk quartile.

A comparison of smokers versus non-smokers demonstrated that smokers experienced higher rates of inpatient (p = 0.025) and 30-day (p = 0.048) mortality, myocardial infarction (p < 0.01), acute respiratory failure (p < 0.01), and a longer length of stay (p = 0.014). Comparison among BMI cohorts demonstrated that underweight patients experienced higher rates of pneumonia (p = 0.033), decubitus ulcers (p = 0.046), and the need for an intensive care unit (ICU) (p < 0.01). AUROC comparison demonstrated that STTGMA_MODIFIABLEsignificantlyimproved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE(0.792 vs. 0.672, p = 0.0445). Quartile stratification demonstrated the highest risk cohort had a longer length of stay (p < 0.01), higher rates of inpatient (p < 0.01) and 30-day mortality (p < 0.01), and need for an ICU (p < 0.01) compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p < 0.01).

Smoking, obesity, and being below a healthy body weight increase the risk of perioperative complications and poor outcomes. Including smoking and BMI improves the STTGMAHIP_FX_SCOREtool to predict mortality and risk stratify patient outcomes. Because smoking, obesity, and being below a healthy body weight are modifiable patient factors, providers can counsel patients and implement lifestyle changes to potentially decrease their risk of longer-term poor outcomes, especially in the setting of another fracture.For patients who are former smokers, providers can use this information to encourage continued restraint and healthy choices.

The worldwide population is aging. The World Health Organization (WHO) predicts that by 2030, one in six people will be 60 years old or older [1]. This trend toward an older population carries with it a higher risk of falls or accidents with subsequent orthopedic injuries. For example, the 2016 National Trauma Database found that patients older than 55 years of age comprised 42.6% of overall trauma and 57.6% of the deaths associated with these traumas [2]. Hip fractures, in particular, carry high rates of morbidity and mortality in the geriatric population [3]. Associated factors for poor outcomes in these patients include age, male gender, the presence of comorbidities, delayed time to surgery, and baseline ambulatory status [4,5]. As age, and to a certain degree, comorbidities are non-modifiable risk factors, it is important to consider factors that can be modified to lower a patients risk.

Body mass index (BMI) and smoking status are two such modifiable risk factors. Literature regarding the association of BMI and mortality or morbidity risk following hip fracture is divided. Despite an apparent obesity paradox, with obese patients having a lower risk of mortality, several studies have found contrasting results where obese, super-obese, and very underweight patients have higher rates of poor outcomes and mortality [6-9]. Similar to BMI, current research has demonstrated smoking to be associated with worse perioperative outcomes and higher rates of mortality following surgery [10-13]. Tobacco smoking is the leading cause of premature mortality that can be adjusted through behavioral changes, regardless of tobacco amount, as Qin et al. reported that even light smoking, that is, one to two cigarettes a day, can increase a patients all-cause mortality [14-16]. In former smokers, understanding the increased mortality risks is important to be able to provide preventative medicine and help these patients to remain smoke-free.

As hip fractures carry a significantly high rate of morbidity and mortality at baseline, it is important to consider strategies to decrease a patients mortality risk. Addressing and understanding modifiable risk factors is one way providers can intervene to improve outcomes. The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated inpatient mortality risk assessment tool for middle-aged and geriatric patients 55 and older who sustain different orthopedic trauma injuries [17]. The original STTGMA tool utilized clinical data available at the time of arrival to the emergency department (ED) to calculate a mortality risk score. Variables included in the original STTGMA tool were a patients age, injury details, Glasgow Coma Scale (GCS) score, and comorbidity profile as defined by the Charlson Comorbidity Index (CCI) [17]. Since STTGMAs inception, the model has evolved to include additional variables such as a patients baseline ambulatory status, American Society of Anesthesiologists (ASA) score, and their coronavirus disease 2019 (COVID-19) status on hospital admission [18-20].

The purpose of this study is to determine whether the inclusion of two additional modifiable clinical variables, BMI and smoking status, would further improve the predictive capacity and risk stratification regarding inpatient mortality for geriatric and middle-aged patients treated for hip fractures. We hypothesize that the addition of these modifiable risk factors will improve predictive capacity.

This is a retrospective cohort study. An Institutional Review Board-approved trauma database was queried for all patients aged 55 and older who sustained a low-energy hip fracture (low energy defined as a fall from standing or from a height of fewer than two stairs) between October 2014 and August 2021. All patients were treated at one urban academic medical center. Fracture patterns included in our analysis were subtrochanteric, femoral neck, or intertrochanteric hip fractures [AO Foundation/Orthopaedic Trauma Association fracture classifications: 31A, 31B, 32(A-C)].Patients were excluded if they were younger than 55 years old or had a high-energy mechanism of injury.

Each patients chart was reviewed for demographics that included age, BMI, gender, smoking status, baseline ambulatory status, and comorbidities using CCI. Smoking status was recorded as a current every-day smoker, former smoker, or never smoker. On a pre-study analysis, as current and former smokers were found to have no differences in complication, hospital quality, or mortality rates, these patients were grouped for analysis. Therefore, patients were considered smokers if they were current or former smokers. BMI was defined as underweight (<18.5 kg/m2), healthy weight (18.5-24.9 kg/m2), overweight (25.0-24.9 kg/m2), or obese (>30 kg/m2). Injury presentation variables collected were GCS scores and Abbreviated Injury Severity scores (AIS) for both the Head/Neck (AIS H/N) and Chest (AIS C).

Hospital quality measures collected were the length of stay (LOS) in days, the need for admission to the Intensive Care Unit (ICU), and discharge home (home was defined as either home independently or home with a health service). Mortality measures collected included inpatient and 30-day mortality. Inpatient complications recorded during each patients admission included sepsis/septic shock, pneumonia, deep vein thrombus/pulmonary embolism (DVT/PE), myocardial infarction (MI), acute renal failure/acute kidney injury (AKI), stroke, surgical site infection (SSI), decubitus ulcer, urinary tract infection (UTI), acute respiratory failure (ARF), anemia, and cardiac arrest.

Patients were initially grouped based on their smoking status, smokers (current and former) versus non-smokers (never smokers), and BMIs. Comparative analyses were conducted between each of these cohorts.For each patient, the baseline STTGMA score for hip fractures (STTGMAHIP_FX_SCORE) was calculated. The model was then adapted to include a patients BMI and smoking status (current every-day smoker, former smoker, or never smoker). A new mortality risk score, STTGMA_MODIFIABLE, was calculated for each patient. The predictive ability of each model was then compared using DeLongs test to assess the area under the receiver operating curves (AUROCs). Then, patients were stratified into risk quartiles based on their new respective STTGMA_MODIFIABLE mortality risk scores. Comparative analyses were conducted on each risk quartile to assess the efficacy of the new BMI and smoking status factors.

The following statistical tests were used as appropriate: Mann-Whitney U tests, chi-square tests, independent-sample t-tests, and analysis of variance (ANOVA). All statistics were calculated using SPSS Version 25 (IBM Corp., Armonk, NY, USA). The significance for this study was defined with an alpha of 0.05.

In total, 2,421 patients met the inclusion criteria. Characteristics for the total cohort were as follows: 69% of patients were female, the mean age was 80.7 10.2 years, mean BMI was 24.17 4.94 kg/m2, median GCS score was 15 (interquartile range (IQR): 0), mean CCI was 1.49 1.73, mean AIS Head/Neck was 0.03 0.27, and mean AIS Chest was 0.02 0.19.The majority of patients were White (71.71%). At baseline, most patients were community ambulators (67.91%), while 28.17% of patients were household ambulators, and 3.92% were non-ambulatory (Table 1).

An initial comparison of the current versus former smoker cohorts demonstrated that there were no differences in complication risk, hospital quality measures, or mortality outcomes (p > 0.05 for all). Subsequently, former and current smokers were grouped for further analysis. When comparing the smoker versus non-smoker cohorts, patients who were currently smoking or had a history of smoking experienced higher rates of inpatient (2.85% vs. 1.52%, p = 0.025) and 30-day (5.60% vs. 3.88%, p = 0.048) mortality. They also had higher rates of MI (2.01% vs. 0.76%, p < 0.01) and ARF (6.98% vs. 3.39%, p < 0.01), and had a longer inpatient LOS (in days: 6.82 4.83 vs. 6.28 4.17, p = 0.037) (Table 2).

Comparison among BMI cut-off cohorts demonstrated that underweight patients experienced higher rates of pneumonia (p = 0.033), decubitus ulcers (p=0.046), and need for the ICU (p < 0.01) (Table 3).

When comparing each risk scores respective AUROC, STTGMA_MODIFIABLE was found to improve the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.792 vs. 0.672, p = 0.0445) (Figure 1).

Regression weighting showed a coefficient of 0.337, with current smokers having the greatest absolute effect size (current every-day smoker = 1.011, former smoker = 0.674). While our other study findings demonstrate being below a healthy body weight increases the risk of inpatient mortality, BMI had a regression coefficient of 0.116, suggesting that a very high BMI is more strongly positively correlated with a higher risk of inpatient mortality. While this demonstrates statistically that a higherBMI positively correlates with a higher risk of inpatient mortality, our additional study findings demonstrate being below a healthy body weight similarly increases the risk of inpatient mortality.

When comparing risk quartiles for STTGMA_MODIFIABLE, multiple outcomes had significance. For mortality, patients in the highest risk quartile (STTGMA score >2.50%) experienced the highest rates of both inpatient (p < 0.01) and 30-day (p < 0.01) mortality. Patients in the highest risk cohort similarly experienced a longer inpatient LOS (p < 0.01), higher rates of sepsis (p < 0.01), pneumonia (p < 0.01), DVT/PE (p = 0.015), MI (p = 0.032), AKI (p < 0.01), ARF (p < 0.01), anemia (p < 0.01), cardiac arrest (p < 0.01), need for ICU level of care (p < 0.01), and were the least likely to be discharged home (p < 0.01) (Table 4).

The purpose of this study was to assess if the addition of various modifiable risk factors, a patients BMI and smoking status, to a validated inpatient mortality risk assessment tool improved the models predictive capacity and ability to effectively triage geriatric and middle-aged patients treated for hip fracture. This study demonstrates that the addition of these modifiable risk factors provided an improved predictive model. This improved mortality risk model will help guide treatment decisions and provide valuable prognostic information to discuss expectations surrounding patients injuries and potential outcomes with patients and their families.

This study demonstrated that patients who are either current smokers or have a history of smoking are at a higher risk for perioperative complications and potentially worse outcomes. While the higher mortality rate cannot be linked solely to a patients smoking status, the higher mortality rates found in our study align with those reported in the literature [11,12].The higher rates of MI and ARF seen in smokers can be expected as well due to the well-documented cardiovascular and pulmonary diseases found in patients secondary to smoking history [21,22]. Longer hospitalizations may also be attributed to the higher complication rates as patients in the smoker cohort required extended hospital stays to improve their health status before discharge. Similarly, these patients had worse baseline statuses prior to the injury, potentially necessitating a longer inpatient course. In addition, it is well documented in the literature that smoking delays wound healing [23-25]. For patients who required surgery as a part of their treatment for hip fracture, it is possible that they needed a longer time to heal due to the detrimental wound healing effects caused by smoking. While in our study, the rate of decubitus ulcer was higher in the smoker cohort, it was not significant. This may be due to the size of our patient cohort; given a larger patient cohort, we may have seen higher rates of decubitus ulcers. In addition, we did not capture the rate of wound infections which could also impact LOS. While the causes of the higher perioperative and mortality rates are multifactorial, smoking likely played a role. Smoking cessation has been proven to improve underlying cardiovascular and pulmonary health [26]. Providers may use this knowledge to counsel patients on the importance of both smoking cessation and/or continuing to remain smoke-free.

This study also demonstrated that patients who are underweightare at a higher risk for perioperative complications and potentially worse outcomes. Patients with a BMI of less than 18.5 kg/m2 were found to be at higher risk for pneumonia, decubitus ulcers, and the need for the ICU. Patients who are underweight may be malnourished and have vitamin deficiencies that impact immune function and wound healing, placing them at higher risk for skin breakdown. An international pressure ulcer prevalence survey and a study by Hyun et al. found that underweight and extremely obese patients were at higher risk for pressure ulcers [27]. Several studies have shown that the risk of infection, such as pneumonia, follows a U-shaped curve, suggesting that both underweight and obese patients are at higher risk [28,29]. While we saw a higher risk of pneumonia in the underweight cohort, it is possible that in our study, by not further splitting super-obese patients from obese patients, we did not see a higher risk of pneumonia in the higher BMI group. Additionally, while our study found that patients who are below a healthy body weight also had a higher risk of inpatient mortality, our regression showed that the higher a patients BMI, the higher the risk of inpatient mortality, similar to that found in the literature [8]. Obesity is associated with several comorbidities such as diabetes, heart disease, and increased risk for stroke, all health issues that have higher rates of mortality [27,30]. Patients who are underweight or obese can be identified as higher risk on arrival, allowing for timely intervention and appropriate medical management. Prior to discharge, counseling can be provided on effective nutrition plans and active lifestyle adjustments to help patients attain healthy body weight.

The inclusion of these modifiable risk factors in the STTGMA tool allowed for effective triage of high-risk patients into appropriate risk quartiles. Stratification using STTGMA_MODIFIABLE identified patients who experienced not only higher rates of inpatient mortality, 30-day mortality, and the need for the ICU but also higher rates of serious inpatient complications such as sepsis, DVT/PE, MI, and AKI. Providers may use these added clinical variables to better identify patients who may require more intensive medical management and timely intervention. This may have implications to improve outcomes and reduce hospital costs by proactively managing patients to help lower complication and mortality rates while shortening hospital admissions.

This study has several limitations. First, as a retrospective study, it is subject to the common biases associated with this study format. Second, our analysis relied upon database entries for a patients smoking status. Therefore, we were unable to assess a patients smoking status if it was not recorded in the electronic medical record (EMR). However, as only 30 patients did not have a smoking status EMR entry, the impact of this limitation may be minimal. Third, our study did not include the number of cigarettes, packs, and pack-years for each patient. As the adverse effects of tobacco smoking may have a dose-dependent relationship, our analysis could not account for this component of a patients smoking status. Further analysis may be done to include a weighting factor that considers smoking amount. Fourth, our study did not distinguish super-obese patients from obese patients. There may be an additional risk or protective factors associated with super-obese patients. Additional studies may also be conducted to include a cost analysis to assess the impact of different BMIs and smoking status on hospital costs. Lastly, future studies may focus on a prospective analysis comparing mortality risks overtime in a cohort that modifies its risk (i.e., by losing weight or stopping smoking) versus a cohort that does not.

Smoking, obesity, and being below a healthy body weight increase the risk of perioperative complications and poor outcomes. Including smoking and BMI improves the STTGMAHIP_FX_SCOREtool to predict mortality and risk stratify patient outcomes. Because smoking, obesity, and being below a healthy body weight are modifiable patient factors, providers can counsel patients and implement lifestyle changes to potentially decrease their risk of longer-term poor outcomes, especially in the setting of another fracture. For patients who are former smokers, providers can use this information to encourage continued restraint and healthy choices.

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The Role of Smoking and Body Mass Index in Mortality Risk Assessment for Geriatric Hip Fracture Patients - Cureus