Treatment and survival among elderly Americans with hip fractures: a population-based study

Measuring the outcomes and pharmacoeconomic consequences of venous thromboembolism prophylaxis in major orthopaedic surgery

Patients who have undergone orthopaedic surgery represent a high-risk group for venous thromboembolism (VTE). Despite the routine prophylactic use of antithrombotic agents, patients still experience thrombotic events that can result in mortality and acute morbidity and, in significant numbers of patients, may lead to long-term consequences such as the post-thrombotic syndrome. Increasingly, initial VTE events occur after hospital discharge since the length of stay in hospital after major orthopaedic surgery has decreased in many countries. There is a need for further improvement in the prevention of VTE. As well as undergoing extensive safety and efficacy studies for registration purposes, new prophylactic strategies need to be evaluated from a pharmacoeconomic perspective to help guide their introduction into routine clinical practice. Over the past 15 years a number of pharmacoeconomic evaluation studies of VTE prophylaxis have been carried out in orthopaedic patients, most of which evaluated short-term clinical endpoints. During the same period, improvements in our understanding of the natural history of VTE as well as the emergence of new treatments have led to changes in the management of patients with, or at risk of, VTE. The aim of this paper was to address how best to conduct pharmacoeconomic analyses of new antithrombotic agents in light of changes in practice patterns for orthopaedic patients and greater understanding of the disease process. We put forward recommendations for relevant outcome measures, timeframes, endpoints and epidemiologic data sources. We also suggest a structure for a pharmacoeconomic model. In this model, the outcomes and costs of VTE-related care during both the acute and chronic phases of the disease are incorporated. Symptomatic deep vein thrombosis and pulmonary embolism, recurrent VTE, post-thrombotic syndrome, major hemorrhage and all-cause death are included. We also recommend that the relevance of quality-adjusted survival is investigated, and that economic appraisals are presented in both cost-consequence and budget-impact approaches. These recommendations are based on extensive examination of recent advances in the management of VTE combined with a greater understanding of its natural history.

Hip fracture in the older patient: reasons for delay in hospitalization and timing of surgical repair

OBJECTIVES

To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the New York City metropolitan area.

PARTICIPANTS

Consecutive patients aged 50 and older admitted with diagnosis of hip fracture to these four hospitals between August 1997 and August 1998.

MEASUREMENTS

Time of injury, time of arrival to the emergency room, and time of surgery were recorded and used to calculate intervals between injury and hospital arrival and between hospital arrival and surgical repair.

RESULTS

Of the 571 patients enrolled, 99 (17%) arrived at the hospital more than 24 hours after injury. After hospital arrival, 17 (3%) patients did not have surgery, 166 (29%) had surgery within 24 hours of arrival, and 388 (68.0%) had surgery more than 24 hours after arrival (median 41 hours, range 25-584). For those patients who had surgery after 24 hours, 163 (29.4%) had surgery 25 to 36 hours after hospital arrival, 102 (18.4%) had surgery 37 to 48 hours after arrival, and 123 (22.2%) had surgery more than 48 hours after arrival. The primary reasons for delaying surgery more than 24 hours after hospital arrival were waiting for routine medical clearance (52%) and unavailability of the operating suite or surgeon (29%). Stabilization of associated medical conditions resulted in the lengthiest periods of delay.

CONCLUSION

A wait time of more than 24 hours from hospitalization to surgical repair of hip fracture in older patients is common. Some of this delay time is patient related and some occurs because of systems factors and may be avoidable. The extent to which surgical timing affects survival and functional recovery needs more detailed examination.

The effects of time-to-surgery on mortality and morbidity in patients following hip fracture

PURPOSE

There is a perception that the standard of care is to repair hip fractures surgically within 24 hours of hospitalization. However, it is unclear whether this reduces mortality or morbidity.

SUBJECTS AND METHODS

We performed a retrospective study in consecutive hip fracture patients, aged 60 years or older, who underwent surgical repair. Patients with metastatic cancer, trauma, or a fracture occurring >48 hours before admission were excluded. The primary outcome was long-term (up to 18 years) mortality. Secondary outcomes included 30-day mortality and decubitus ulcers, serious bacterial infections, myocardial infarction, and thromboembolism. Analyses were adjusted for medical conditions; the comparison group comprised patients who underwent surgery for hip fracture repair within 24 to 48 hours because there were no patients with active medical problems who underwent surgery within 24 hours.

RESULTS

Of the 8383 patients, surgery was delayed for more than 24 hours in 2464 patients (29%) for medical reasons and in 1341 patients (16%) without active medical problems. Compared with those who underwent surgery 24 to 48 hours after admission to the hospital, patients who underwent surgery more than 96 hours after admission did not have increased long-term mortality (hazard ratio = 1.07; 95% confidence interval [CI]: 0.95 to 1.21), although the risk of decubitus ulcer was increased (odds ratio = 2.2; 95% CI: 1.6 to 3.1). There were no associations between time-to-surgery and the other secondary outcomes.

CONCLUSION

Time-to-surgery in hip fracture patients was not associated with short- or long-term mortality after adjusting for active medical problems. Other than increasing the risk of decubitus ulcer formation, waiting did not appear to affect patients' outcomes adversely.

The effects of knowledge, attitudes, and significant others on decisions to enroll in a clinical trial on osteoporosis: implications for recruitment of older African-American women

This preliminary study explored the roles of knowledge, attitudes, and significant others on decisions of older African-American women to enroll in a clinical trial involving estrogen and osteoporosis. Sixteen older African-American women (average age 75 years) participated in three focus groups. Twelve of the women had enrolled in the clinical trial and four, although eligible, refused to enroll. Discussions revealed that knowledge of osteoporosis and estrogen and expectations of personal rewards and group benefits from medical research appear to differentiate the women who participated in the clinical trial from those who refused. The women who participated also perceived the research institution as accessible. In addition, assuring full disclosure of testing procedures and test results eased their apprehensions about participation. However, the women who refused to enroll saw no personal benefit and were unwilling to expose themselves, in part because of their age, to the risks of taking estrogen and the uncertain outcomes of the clinical trial. The study illustrates how focus groups can be used to develop multiple strategies to enable recruitment of older African-American women with different demographic characteristics, levels of knowledge, and attitudes toward a disease and medical research.

Medical care of elderly patients with hip fractures

Medical morbidity associated with hip fractures in the elderly population is considerable. The all-cause mortality rate is 24% at 12 months. The functional limitations of survivors can be pronounced. As the American population ages, hip fractures will substantially affect the utilization of hospital resources. Several issues, including preoperative clearance and related surgical timing, deep venous thrombosis prophylaxis, delirium, nutrition, and urinary tract management, are important in the care of these patients. A close partnership between orthopedic surgeons and clinicians provides the best strategy of care for the subset of patients with multisystemic complications.

Unresolved issues in osteoporosis in men

Fragility fractures in men are a public health problem. The increasing longevity in men is likely to increase the public health burden of fractures in men. This problem remains unrecognized by doctors, the public and governments. About one third of all hip fractures occur in men but the incidence and gender ratio varies from country to country for reasons that are not understood. The prevalence of spine fractures is about half that of women in most studies, but similar to that of women in several other studies. The incidence of spine fractures is uncertain but is likely to be about half that of women except in 80+ year olds, when it appears to be similar. The causes of the higher mortality in men than in women following hip or spine fracture are not well defined. Areal bone mineral density (aBMD) predicts fracture risk in men; the relative risk for spine and hip fracture conferred by a 1 SD lower aBMD, or by a prevalent fracture, is similar in men and women. The age-specific absolute risk (number of cases per 1,000 per year) conferred by a given hip aBMD is similar in men and women. The age-specific absolute risk conferred by aBMD at the calcaneus or radius for spine fracture is similar for men and women. If the absolute and relative risks are similar then the lower incidence of fractures in men than women may reflect the lower proportion of the male population distribution below a given structural determinant of bone fragility. That is, at any age, there may be fewer men than women with smaller bones, lower volumetric bone mineral density (vBMD), thinner trabeculae or cortices, architectural disruption, or higher remodeling rates. Higher mortality and fewer falls may also contribute to the lower incidence of fractures in men. This tail end of the male population distribution (for traits like bone size, vBMD, architecture, and remodeling rates) is the likely source of fracture cases in males. Hypogonadism is a risk factor for osteoporosis. However, the definition, prevalence, causes and structural consequence of hypogonadism are inadequately defined. At what level of testosterone is bone balance negative? What structural determinants of axial and appendicular strength are regulated by testosterone, estrogen, growth hormone (GH), insulin like growth factor 1 (IGF-1) (or their interactions)? Is reduced bone size in men with spine or hip fractures due to failed growth-related or age-related periosteal expansion? If reduced vBMD is due to reduced accrual, is this due to reduced cortical thickness? What factors regulate and coregulate the periosteal and endocortical modeling and remodeling? Are reduced trabecular numbers due to failed formation at the growth plate, excess resorption of primary trabeculae or reduced formation of secondary trabeculae? Is reduced trabecular thickness due to failed prepubertal or pubertal bone formation? Is reduced cortical and trabecular thickness during aging due to excessive endosteal resorption or reduced bone formation? If the former, is this due to increased remodeling sites or increased resorption depth? Most evidence favors reduced bone formation as the cause of bone loss with trabecular bone loss occurring by reduced formation and thinning more than by increased resorption and loss of connectivity. Cortical bone loss is less than in women because endocortical resorption is less and periosteal apposition is greater. If the reduced bone formation is most important, is this due to reduced osteoprogenitors, reduced osteoblast matrix synthesis or early osteoblast apoptosis? Anti-spine-fracture efficacy has been demonstrated in only one randomized heated with alendronate drug in men. The gaps in our knowledge remain large.

Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture--a randomized controlled trial

BACKGROUND

Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery. The impact of analgesic management on the incidence and severity of cardiac ischemia was studied in 77 elderly patients undergoing surgical treatment of traumatic hip fracture.

METHODS

After hospital admission and written consent, patients were randomised to conventional analgesic regimen (intramuscular oxycodone, OPI group) or continuous epidural infusion of bupivacaine/fentanyl (EPI group). The analgesic regimens were started preoperatively. Patients were operated under spinal anaesthesia and the treatments were continued three days postoperatively. ECG was continuously recorded. ST segment depression of > or = 0.1 mV or elevation of > or = 0.2 mV lasting > or = 1 min were considered as ischaemic episodes. Nocturnal arterial oxygen saturation (SaO2) was recorded perioperatively, and subjective pain was assessed every morning using a visual analogue scale (VAS).

RESULTS

Fifty-nine (OPI 30, EPI 29) patients were evaluable for efficacy. Thirteen patients (43%) in the OPI and 12 patients (41%) in the EPI group had ischaemic episodes (NS). However, significantly more patients in the OPI group had ischaemic episodes during the surgery (8 vs. 0 in the EPI group, P=0.005). The median (quartal deviation) total ischaemic burden (i.e. integral of ST-change vs. time) in patients with ischaemic episodes was ten times larger in the OPI group (340 [342] mm x min) compared with the EPI group (30 [36] mm x min) (P=0.002). There were no significant differences between the groups in average heart rates or in heart rates at the start of ischaemic episodes or in maximal heart rates during the attacks. Average nocturnal SaO2 was similar in the two groups and there were no differences in the number of hypoxaemic (SaO2<90%) episodes. Preoperatively there were no differences in subjective pain, but postoperative and average perioperative VAS scores for pain were almost 40% lower in the EPI group (P=0.006). Perioperative myocardial infarctions were not detected.

CONCLUSIONS

Continuous epidural bupivacaine/fentanyl analgesic regimen, started preoperatively, reduces the amount of myocardial ischaemia in elderly patients with hip fracture.

Physical function and fear of falling after hip fracture rehabilitation in the elderly

OBJECTIVE

The purpose of this study was to determine the relationship between physical function and fall-related self-efficacy in older patients with a hip fracture who are undergoing an intensive rehabilitation program.

DESIGN

We used a prospective cohort study over 12 mo to determine the effect of a specialized hip fracture rehabilitation program in a geriatric hospital on physical function and fear of falling. Fifty-six patients were admitted consecutively from acute care. Physical function was assessed using the Functional Independence Measure, and fall-related self-efficacy was measured using two scales: the Falls-Efficacy scale and the Activities-Specific Balance Confidence scale. We also used the Vitality scale to measure quality of life. All measures, represented by change scores, were determined at the beginning and end of the patients' rehabilitation programs.

RESULTS

Significant improvement in physical function and fall self-efficacy was observed. The Vitality scale was also improved after rehabilitation. The Falls-Efficacy scale appeared to be more sensitive to change than the Activities-Specific Balance Confidence scale, whereas no correlation was found between changes in the fall-related self-efficacy measures and the Functional Independence Measure.

CONCLUSIONS

These findings may represent a discrepancy between attention of the rehabilitation program on functional outcomes and less emphasis on confidence building behaviors. Restrictions in function from a fear of falling may negate any gains made through rehabilitation, and this could limit the long-term success of these programs and patient outcomes after hip fracture.

Balance, mobility, and falls among elderly African American women

OBJECTIVE

To compare balance, mobility, recent falls, and injuries among elderly African American and white women.

DESIGN

This was a nonexperimental study. Participants, who were older than 65 yr of age, able to walk at least 30 ft, not residing in a nursing home, and with no acute medical problems, were recruited from 17 senior citizens' community centers.

RESULTS

Compared with white women (n=180), African American women (n = 118) took fewer medications, had greater body mass indexes, had less muscle strength, and had more medical conditions and neurologic abnormalities. Additionally, these women were less active and had poorer performances on an obstacle course. The two groups had a similar histories of falls and injuries. For both groups, activity level and neurologic findings were predictors of obstacle course performance. For white women, muscle strength was an additional predictor of obstacle course performance. An additional predictor for African American women was range of motion.

CONCLUSION

The poorer balance and mobility of African American women compared with white women may have consequences such as their functional dependence, resulting in their greater use of hospitals and formal and informal health services.

Bone mineral density 6 years after a hip fracture: a prospective, longitudinal study

The purpose of this prospective study was to extend the results of previous studies to determine if an accelerated rate of loss of bone mineral density (BMD) continues for 6 years after a hip fracture. Eighty-five elderly patients who had sustained a hip fracture had determinations of BMD made at the time of fracture; 55 of these patients were available for reassessment of BMD 1 year later, and 21 were available for reassessment of BMD 6 to 7 years later. The change in BMD from injury to 1 year and from 1 to 6 years was determined and correlated with pre- and postinjury variables, such as ambulatory ability, dietary intake of calcium, serum vitamin D levels, and mental status. There was a marked decrease in BMD in the in the first year after fracture, with the mean change in BMD being -4.3% at the femoral neck and -1.8% at the lumbar spine. Between 1 and 6 years after fracture, however, there was a dramatic increase in the BMD at both the femoral neck and lumbar spine measurement sites. Relative to 1 year after fracture, the mean increases were 7.7% at the femoral neck and 4.5% at the lumbar spine. In many cases, the loss of bone mineral that occurred in the first year after fracture was completely recouped in the subsequent 5 years. Five of the 21 patients (24%) sustained a contralateral hip fracture in the 6 years after the index fracture. Lumbar spine BMD was lower at baseline (p = 0.112), 1 year after fracture (p = 0.007), and 6 years after fracture (p = 0.003) in patients who sustained a second hip fracture than in those who did not. There was a general decrease in the functional activity level of patients in the 6 years after a hip fracture, but there were no statistically significant relationships between changes in BMD and the functional mobility of patients. The mean calcium intake in patients improved remarkably in the 6 years after fracture, but there was no correlation between daily calcium intake and changes in BMD. During the first year after a hip fracture, there is a rapid loss of bone mineral from the lumbar spine and contralateral femoral neck. Between 1 and 6 years after fracture, however, BMD is likely to increase, perhaps to levels greater than those at baseline. Although this investigation is small, the findings of this study point to the importance of further larger studies to further clarify the natural history of BMD after a hip fracture and the potential impact of pharmacological intervention on that natural history.

The impact of race and fractures on mortality in a postmenopausal Medicaid population

The purpose of this study was to model fractures and survival by age and race in a large postmenopausal Medicaid population. All Georgia Medicaid claims were abstracted for the years 1992, 1993, and 1994. Claims for postmenopausal women (> or =50 years of age) were retained, and patients with fractures were identified by International Classification of Diseases, Ninth Revision codes for fracture. A survival analysis was conducted using Kaplan-Meier estimators to evaluate the effect of fracture, age, and race on 3-year survival. A total of 159,400 white and black postmenopausal women were identified. The cohort with fracture totaled 5933 patients, with femoral fractures constituting 46% of all fractures. Discounting those with fracture before the study, the fracture incidence was approximately 1.2% in this postmenopausal female cohort. The survival analysis suggested that after age was accounted for, black postmenopausal women had a 42% increased risk of death within 3 years of fracture, compared with 13% for white women. However, postmenopausal black women were approximately 50% less likely to experience a fracture, and postmenopausal black women without fracture had better survival rates than comparable white women. Mortality crossover and the diminished likelihood of fracture mask the true nature of fracture survival in postmenopausal black women. Postmenopausal black women with fracture are at greater risk of dying than their white counterparts.

Cervical spine fractures in the elderly: factors influencing survival in 65 cases

To evaluate whether a cervical spine fracture increases the death risk in elderly patients, and to define risk factors, we studied the survival of 65 patients (26 women) with a mean age of 77 (66-99) years. 8 of the patients were tetraparetic. In 35 patients, the upper cervical spine was fractured. 7 patients suffered from ankylosing spondylitis. Severe co-morbidity was present in 16. Survival status and the date of death were retrieved from the government official personal registry. The expected survival was calculated from data retrieved from the Swedish National Board of Health and Welfare. Variables having a possible relation with survival (i.e., a p-value < 0.10 when entered into a Kaplan-Meier survival analysis) were used in a Cox multiple regression survival analysis. 53 (24-105) months after injury, 25 of the 65 patients had died. The survival was significantly lower than the expected values. Severe co-morbidity (risk ratio: 5,6), neurological injury (6,4), high age (1,1), and ankylosing spondylitis (5,5) proved to be significant risk factors for death. Thus, a cervical spine fracture may lead to earlier death in a patient with a severe co-morbidity. A neurological complication constitutes a risk also for a previously healthy individual. Patients having ankylosing spondylitis (with increased death risk) run a higher than normal risk of sustaining a cervical spine fracture.

Costs and outcomes of hip fracture and stroke, 1984 to 1994

OBJECTIVES

This study quantified changes in Medicare payments and outcomes for hip fracture and stroke from 1984 to 1994.

METHODS

We studied National Long Term Care Survey respondents who were hospitalized for hip fracture (n = 887) or stroke (n = 878) occurring between 1984 and 1994. Changes in Medicare payment and survival were primary outcomes. We also assessed changes in functional and cognitive status.

RESULTS

Medicare payments within 6 months increased following hip fracture (103%) or stroke (51%). Survival improved for stroke (P < .001) and to a lesser extent for hip fracture (P = .16). Condition-specific improvements were found in functional and cognitive status.

CONCLUSIONS

During the period 1984 to 1994, Medicare payments for hip fracture and stroke rose and there were some improvements in survival and other outcomes.

Mortality after all major types of osteoporotic fracture in men and women: an observational study

BACKGROUND

Mortality increases after hip fractures in women and more so in men. Little is known, however, about mortality after other fractures. We investigated the mortality associated with all fracture types in elderly women and men.

METHODS

We did a 5-year prospective cohort study in the semi-urban city of Dubbo, Australia, of all residents aged 60 years and older (2413 women and 1898 men). Low-trauma osteoporotic fractures that occurred between 1989 and 1994, confirmed by radiography and personal interview, were classified as proximal femur, vertebral, and groupings of other major and minor fractures. We calculated standardised mortality rates from death certificates for people with fractures compared with the Dubbo population.

FINDINGS

356 women and 137 men had low-trauma fractures. In women and men, mortality was increased in the first year after all major fractures. In women, age-standardised mortality ratios were 2.18 (95% CI 2.03-2.32) for proximal femur, 1.66 (1.51-1.80) for vertebral, 1.92 (1.70-2.14) for other major, and 0.75 (0.66-0.84) for minor fractures. In men, these ratios were 3.17 (2.90-3.44) for proximal femur, 2.38 (2.17-2.59) for vertebral, 2.22 (1.91-2.52) for other major, and 1.45 (1.25-1.65) for minor fractures. There were excess deaths (excluding minor fractures in women) in all age-groups.

INTERPRETATION

All major fractures were associated with increased mortality, especially in men. The loss of potential years of life in the younger age-group shows that preventative strategies for fracture should not focus on older patients at the expense of younger women and of men.

Do hip replacements improve outcomes for hip fracture patients?

BACKGROUND

Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority.

OBJECTIVES

To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation).

DESIGN

Prospective cohort study.

PARTICIPANTS

We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive.

MEASUREMENTS

We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year).

RESULTS

Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02).

CONCLUSIONS

Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.

An economic evaluation of energy-absorbing flooring to prevent hip fractures

An economic evaluation of energy-absorbing flooring designed to prevent hip fractures revealed a payback period of 10 1/2 years if only direct costs avoided were evaluated and just over 11 months when direct and indirect costs were included. Cost-effectiveness ratios of less than $0 per hip fracture prevented and life year saved were also estimated.

Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture

OBJECTIVE

To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture.

DESIGN

Prospective comparative survey design.

PARTICIPANTS

A convenience sample of 88 hip fracture patients (53 cognitively impaired, 35 cognitively intact) from three Midwestern urban hospital orthopedic units was interviewed between days 2 and 5 postoperatively. Subjects whose Folstein Mini-Mental State Exam (MMSE) score was less than or equal to 23 were categorized as impaired.

RESULTS

Pain report and intensity did not differ significantly between the two groups. One-third of the subjects in both groups rated pain as severe or worse. Cognitively impaired subjects scored significantly higher on the Checklist of Nonverbal Pain Indicators observed with movement (CNPI-m) than did cognitively intact subjects. Cognitively impaired subjects received significantly less opioid analgesics than cognitively intact subjects in the first and second 48 hours postoperatively. Both groups received less than 25% of the mean prescribed amount of opioid analgesics. Age, MMSE, and CNPI-m score accounted for 27% of the variance in the amount of opioid analgesic administered in the first 48 hours postoperatively.

CONCLUSIONS

Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.

Effect of tamoxifen on bone fractures in older nursing home residents

OBJECTIVES

To evaluate the association between tamoxifen (TAM) treatment and rate of bone fractures in older, nursing home residents.

PARTICIPANTS

A total of 93,031 women, aged 65 years and older, whose data were part of the 1993 New York State MDS and for whom there was documentation of treatment with at least one medication.

SETTING

New York State long-term care facilities.

DESIGN

Cross-sectional study via secondary analysis of 1385 matched sets of residents. Each set included one resident who was receiving TAM treatment and up to four residents who were not.

MEASUREMENTS

Measurements included age, ethnicity, TAM treatment, hormone replacement therapy, vision impairment, any bone fractures, and, specifically, hip fractures.

RESULTS

During the 1.5-year period for which bone fractures are documented in the 1993 MDS, the fracture rates were: 7.62% in women not treated with TAM, 3.20% in women receiving 10 mg TAM daily, and 6.73% in women receiving 20 mg TAM daily. The odds ratio (OR) for bone fractures among women receiving 20 mg TAM daily compared with nontreated women was 0.916 (95% confidence interval (CI): 0.720-1.164; P = .472), and was 0.312 (95% CI: 0.112-0.865; P = .025) for those receiving 10 mg daily. The rates of hip fracture were 4.98%, 2.40%, and 4.57% for controls and women receiving 10 mg and 20 mg TAM daily, respectively. Whereas the hip fracture rate for women receiving 20 mg daily was statistically similar to that of the controls (OR = .963; 95% CI: 0.718-1.291; P = .800), the difference between the controls and those receiving 10 mg daily approached significance (OR: 0.313; 95% CI: 0.096-1.018; P = .054).

CONCLUSION

Although standard treatment of 20 mg TAM daily offers no apparent protection against bone fracture in older nursing home residents, a daily 10 mg dose seems to be protective.

Hip fracture in the elderly. An interdisciplinary team approach to rehabilitation

The rising incidence of hip fractures in the elderly is a disturbing trend with serious health and socioeconomic consequences, including morbidity, loss of function, long-term institutionalization, and mortality. When preventive measures fail, the interdisciplinary healthcare team works together to provide operative treatment, reduce the risk of postoperative complications, and guide the patient through the recovery process. A team approach that ensures appropriate treatment, careful discharge planning, and coordinated rehabilitation can reduce the impact of the injury, speed recovery, and restore patient independence.

Identifying risk factors for and preventing hip fractures in elderly patients

Changing the mind-set of Americans to exercise more, eat right, and be responsible for their own health throughout the continuum of life is a challenge for all health care professionals. Through personal interaction with patients and participation in hospitalwide or communitywide education programs, perioperative nurses play a key role in educating the public about prevention of hip fractures in elderly patients.

Temporal trends and geographic variations in surgical treatment of femoral neck fractures

BACKGROUND

The objectives of this study were to examine temporal trends in treatment of femoral neck fractures, factors associated with treatment, and variations in practice patterns among counties and hospitals in Ontario, Canada.

METHODS

Hospital discharge data were analyzed. Cases were defined as age > 50 years with a surgically treated femoral neck fracture between 1981 and 1992 (n = 29,391).

RESULTS

The age-adjusted and sex-adjusted proportion of patients treated with hemiarthroplasty (HA) increased from 45% in 1981 to 61% in 1992 (p < 0.0001). HA is more likely to be performed among women, older patients, and nursing home patients. Among counties there was a 38-fold variation for total hip arthroplasty (0.5-38%) and a 9-fold variation in use of HA (9-83%). The degree of variation in treatment was mainly the result of individual hospitals.

CONCLUSION

The wide regional variations in treatment of femoral neck fractures reflect a lack of consensus in Ontario.

In-hospital case-fatality of aged patients with hip fracture in Catalonia, Spain

Hip fracture case-fatality in patients aged 65 years or older was studied in patients admitted to acute care hospitals in Catalonia over a 1-year period. 1222 femoral neck fractures and 1648 pertrochanteric fractures were identified. Women (76.9%) were most frequently and significantly older than men. Average age in pertrochanteric fracture was significantly higher than cervical fracture. The overall in-hospital case-fatality rate was 6.8%. Male gender, advanced age, pertrochanteric fracture and conservative management were associated with a significantly higher case-fatality rate. Multivariate logistic regression analyses demonstrated that previously seen associations showed univariate analysis. However, because interaction was observed, association within fracture and case-fatality was studied separately by gender. Men with pertrochanteric fracture showed the greatest association for in-hospital case-fatality (OR: 3.3; 95% CI: 2-5.5) compared with women with femoral neck fractures. In models with in-hospital case-fatality or no autonomy at discharge or in-hospital case-fatality or no autonomy at discharge or readmission as dependent variables, the odds ratio of death for conservative management of hip fracture were 3.7 (95% CI: 2.3-6) and 3.1 (95% CI: 1.9-4.9), respectively. This information should be taken into consideration for further analyses for long-term outcome and resource consumption by patients with hip fracture.

Osteoporosis in men

Hip fractures in men account for one third of all hip fractures and have a higher mortality than in women. The public health burden will increase as the increase in the numbers of elderly men in the community increases. In addition, the age-specific incidence of hip fractures may be increasing in some, but not all, countries. Vertebral fractures may be a public health problem as recent studies suggest that the prevalence in the community is 20-30%, similar to that reported in women. Forearm fractures should probably not be regarded as a public health problem. Peak bone mass is higher in men than women because men have bigger bones. Peak bone mineral density is the same. The amount of trabecular bone lost at the spine and iliac crest during ageing is similar in men and women. Cortical bone loss is less in men because endocortical resorption is less and periosteal formation is greater. Bone loss accelerates in elderly men because endocortical resorption and increasing cortical porosity increase the surface available for resorption. Bone fragility is less in men than women because: (a) the cross-sectional surface of the bone is larger; (b) trabecular bone loss is less as a percentage of the higher peak bone mass; (c) trabecular bone loss occurs by thinning rather than perforation; and (d) periosteal appositional growth compensates for endocortical resorption by maintaining the bending strength of bone. Reduced BMD in men with fractures may be due to reduced peak bone size and mass, and bone loss. Bone loss occurs by reduced bone formation. Whether men with fractures have increased bone fragility due to reduced periosteal appositional growth during ageing is unknown. The age-related decline in testosterone, adrenal androgens, growth hormone, and insulin-like growth factor 1 may contribute to reduced bone formation and bone loss. Men with vertebral fractures often have hypogonadism or illnesses with few clinical features that should be considered with a high index of suspicion (alcoholism, myeloma, malabsorption, primary hyperparathyroidism, haemochromatosis, Cushing's disease). Secondary hyperparathyroidism may contribute to bone loss by activating bone turnover and so increasing the number of bone remodelling units with impaired bone formation in each. There is no proven treatment for osteoporosis in men because there have been no trials using anti-fracture efficacy as an end point. Testosterone replacement should be considered in men with proven hypogonadism and vitamin D deficiency should be corrected if present. Calcium supplements and bisphosphonates are reasonable options given the lack of information.

Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York state were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

The epidemiology and pathogenesis of osteoporosis

Osteoporosis is an increasing health care concern as populations age throughout the developed and developing world. The social and economic costs of osteoporosis are due to its clinical outcome of fracture which increases exponentially with age. This review will highlight some of the key epidemiological aspects of osteoporosis incorporating areas of more recent interest. These include the definition; the magnitude of the problem encompassing differing incidence and prevalence patterns of both low bone mass and fracture in different cultural groups; the social consequences of fracture, including economic costs, morbidity and mortality; the evaluation of fracture risk, including the role of bone density, bone quality and the risk of falling; as well as an overview of some of the factors involved in determining low bone mass. Bone mineral density (BMD) is the most easily measured and accurate predictor of fracture risk. For any individual, BMD is the combination of their peak bone density and subsequent bone loss, both of which are influenced by genetic, hormonal and environmental factors. An understanding of key issues relating to this important disease may lead to earlier detection of the individual at high risk for fracture and rational approach to prevention and management.

Variations in the performance of hip fracture procedures

OBJECTIVES

Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures.

METHODS

The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities.

RESULTS

The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (P < or = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P > 0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P < 0.001).

CONCLUSIONS

Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

A study of the effects of tamoxifen in the frail elderly: difficulties encountered in nursing home research

OBJECTIVE

This study was conducted in order to determine whether the effects of tamoxifen in elderly, frail nursing home residents are similar to those that have been previously reported for younger postmenopausal women.

DESIGN

A chart review study.

SETTING

The Jewish Home and Hospital for Aged (JHHA), a subacute long-term care facility.

PARTICIPANTS

One hundred fifty-eight women who had been at the JHHA at any time since 1986. One hundred ten had a history of breast cancer; 43 of these had been treated with tamoxifen while at the JHHA (Group I), and 66 had not (Group II). The remaining 49 women had no history of breast cancer (Group III).

MEASUREMENTS

Data were collected from the time of admission to the JHHA through August, 1994 on: chemistry profiles, bone fractures apparently not a consequence of metastasis, gynecological parameters, and thromboemboli.

RESULTS

The lack of pre-admission clinical information presented problems regarding research design and the interpretation of our findings. Nevertheless, compared to women who had not been treated with tamoxifen, treated women had a significantly elevated incidence of vaginal discharge (P = 0.01) and a lower prevalence of elevated total cholesterol (P = 0.04). Although not statistically significant, they also had decreased levels of low density lipoprotein cholesterol and an increased incidence of thromboemboli and bone fractures.

CONCLUSIONS

While some of the effects of tamoxifen in elderly, frail women are similar to those observed in younger, postmenopausal women, others may be different. Our results suggest a need for further innovative studies that focus on the consequences of tamoxifen treatment in the elderly, frail population.

A prospective study on socioeconomic aspects of fracture of the proximal femur

A prospective survey of hip fracture incidence and outcome was conducted to evaluate their socioeconomic impact. Over the course of 1 year, 404 hip fractures were recorded in 339 women and 65 men following minor or moderate trauma. The subjects' ages were 82.8 +/- 10.0 years (mean +/- SD): 84.1 +/- 9.2 in female and 76.4 +/- 13.7 in male subjects. The overall annual incidence was 104.4/100,000; the incidence in women was 167.1 versus 35.3 in men, with a crude female-to-male ratio of 4.7. However, when adjusted for age, this ratio was 2.7. When adjusted to the 1985 U.S.A. population, the incidence rates were 68.6 overall, 108.8 female, and 26.3 male, and were, respectively, 119.1, 188.8, and 46.1 when adjusted to the 1992 Swiss population. As compared with 105 age-matched non-hip-fracture fallers studied in the same emergency ward, fracture subjects lived more often in nursing homes and took cardiovascular drugs (p < 0.001). The mean length of stay in the orthopedic ward was 16.3 +/- 12.0 days (median 14; range 2-193 days), for a total of 6566 bed-days representing 19.8% of available bed-days. The mean length of stay in rehabilitation hospitals was 63.6 +/- 52.6 days (median 50; range 2-349 days), for a total of 17,099 bed-days, representing 5.2% of available bed-days. For patients who where independent before fracture, the greater length of stay was associated with advanced age and consumption of cardiovascular drugs. The total cost of hospital stay amounted to approximately $44,000 per patient. Mortality was 3.2% in the orthopedic ward and 10.8% in rehabilitation hospitals, for an overall in-hospital mortality rate of 10.4%. Overall, the 1-year mortality was 23.8% (21.5% for women and 35.4% for men), and it was significantly higher than in the general population (p < 0.001). Prognostic factors for mortality were age, sex, consumption of cardiovascular drugs, and previous living circumstances. One year after fracture, 62.6% of the fracture patients had returned to their previous living circumstances, but 17.9% needed a more care-intensive environment. The likelihood of returning to autonomous living circumstances 1 year after fracture was higher in younger subjects, in females, in those living with a partner, and in those in overall better health before the fracture. This prospective survey highlights the high socioeconomic impact and burden of osteoporotic fractures of the proximal femur.