Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis

Prognostic value of orthogeriatric assessment parameters on mortality: a 2-year follow-up

Introduction

Since the arise of orthogeriatric co-management patients’ outcome and survival has improved. There are several assessment parameters that screen the precondition of orthogeriatric patients including mobility, activities of daily living, comorbidities, place of residence and need for care just to name a few. In a 2-year follow-up on an orthogeriatric co-managed ward the fracture-independent predictive value of typical assessment parameters and comorbidities on the associated mortality was examined.

Methods

All patients treated on an orthogeriatric co-managed ward from February 2014 to January 2015 were included. No fracture entity was preferred. Emphasis was set on following parameters: age, gender, Parker-Mobility Score (PMS), Barthel Index (BI), Charlson-Comorbidity Index (CCI), dementia, depression, sarcopenia, frequent falling, length of stay (LOS), care level (CL) and place of residence (POR). In a 2-year follow-up the patients’ death rates were acquired. SPSS (IBM Corp., Armonk, New York, USA) and Cox regression was used to univariately analyze the expression of the mentioned parameters and mortality course over 2 years from discharge. In a multivariate analysis intercorrelations and independent relationships were examined.

Results

A follow-up rate of 79.6% by assessing 661 patients was achieved. In the univariate analysis linear inverse correlation between PMS and BI and mortality and a linear positive correlation between CCI and higher mortality were observed. There was also a significant relationship between lower survival and age, dementia, sarcopenia, frequent falling, higher institutionalized place of residence and higher CL. No univariate correlation between 2-year mortality and gender, depression and LOS was found. In the multivariate Cox regression, the only independent risk factors remaining were lower PMS (HR: 1.81; 95%CI: 1.373–2.397), lower BI (HR: 1.64; 95%CI: 1.180–2.290) and higher age per year (HR: 1.04; 95%CI: 1.004–1.067).

Conclusion

Age, PMS, BI, CCI, preexisting dementia, sarcopenia, frequent falling, POR and CL are univariate predictors of survival in the orthogeriatric context. An independency could only be found for PMS, BI and age in our multivariate model. This underlines the importance of preexisting mobility and capability of self-support for the patient’s outcome in terms of survival.

Impact of a geriatric consultation service on outcomes in older trauma patients: a before-after study

PURPOSE

Early geriatric involvement is recommended for older trauma patients. We wished to determine the impact of geriatric consultation on mortality, hospital length of stay and discharge disposition in older patients who were admitted to our Level 1 trauma unit.

METHODS

We completed a health records review of trauma unit patients, age ≥ 75 years old with Injury Severity Score (ISS) ≥ 12, before (11/2015-10/2017) and after (11/2017-10/2019) implementation of a geriatric trauma consultation initiative. Primary outcomes were mortality, hospital length of stay and discharge destination. Secondary objectives were adherence to the geriatric trauma consult process and identification of geriatric-specific issues. A multivariable analysis controlling for age, gender, multi-morbidity and ISS was undertaken.

RESULTS

157 patients pre-implementation and 172 post-implementation with mean age 83.8 years and 53.8% females were included. Geriatric consultation had no impact on in-hospital mortality [OR 0.70 (95% CI 0.31-1.58)] or length of stay [ß 0.68 (95%CI - 1.35-2.72)]. Patients who received a geriatric consultation were more likely to be discharged home (OR 2.01 (95% CI 1.24-3.24). The adherence to consultation process was 99.4%. Mobility, pain and cognitive impairment were the most common geriatric concerns, identified in 76.6, 61.1 and 50.0% of older trauma patients, respectively.

CONCLUSION

Older trauma patients that receive geriatric trauma consultation are more likely to be discharged home. Collaboration between trauma and geriatric specialists is beneficial and may lead to meaningful improvements in outcomes for older trauma patients.

Is the Parker Mobility Score in the older patient with a traumatic hip fracture associated with discharge disposition after surgery? A retrospective cohort study

PURPOSE

The research questions for this study were as follows: (1) is the Parker Mobility Score (PMS) associated with discharge disposition and hospital length of stay (HLOS) of geriatric traumatic hip fracture patients? (2) Can the PMS be incorporated in a decision tree for the prediction of discharge disposition of geriatric traumatic hip fracture patients upon admittance.

METHODS

A dual-center retrospective cohort study was conducted at two level II trauma centers. All patients aged 70 years and older with traumatic hip fractures undergoing surgery in 2018 and 2019 were included consecutively (n = 649). A χ² automatic interaction detection analysis was performed to determine the association of the PMS (and other variables) with discharge disposition and HLOS and predict discharge destination.

RESULTS

The decision tree for discharge disposition classified patients with an overall accuracy of 82.1% and a positive predictive value of 91% for discharge to a rehabilitation facility. The PMS had the second most significant effect on discharge disposition (χ² = 22.409, p < 0.001) after age (χ² = 79.094, p < 0.001). Regarding the tree analysis of HLOS, of all variables in the analysis, PMS had the most significant association with HLOS (F = 14.891, p < 0.001). Patients who were discharged home had a mean HLOS of 6.5 days (SD 8.0), whereas patients who were discharged to an institutional care facility had a mean HLOS of 9.7 days (SD 6.4; p < 0.001).

CONCLUSION

This study shows that the PMS was strongly associated with discharge disposition and HLOS. The decision tree for the discharge disposition of geriatric traumatic hip fracture patients offers a practical solution to start discharge planning upon admittance which could potentially reduce HLOS.

LEVEL OF EVIDENCE

Level III, diagnostic.

Dedicated hip fracture services: A systematic review

BACKGROUND

Hip fractures (HFs) are common and pose a significant burden to both the individual and the community. Prompt operative management and aggressive rehabilitation have been shown to improve outcomes. However, there is often a delay in treatment due to lack of theatre availability and appropriate perioperative multi-disciplinary care. This study reviews the literature and reports on outcomes of HFs treated in dedicated units with allocated theatre time and pre-determined multi-disciplinary perioperative pathways. It also provides comparison against outcomes data from HF registries, both domestically and internationally.

METHODS

An electronic literature search was performed to identify original, English language studies reporting on patient outcomes from dedicated HF units (HFUs). Studies were graded using the Journal of Bone and Joint Surgery criteria. Data were extracted from the text, table and figures of the selected studies.

RESULTS

Five appropriate studies, with a total cohort of 6633 patients (4032 of whom were treated in a dedicated HFU), were identified. Patients treated in these units sustained a lower mortality rate (Risk Ratio  = 0.62, p = 0.01).

CONCLUSIONS

This review demonstrates that centres with dedicated HFUs result in improved 30-day mortality. Further research may demonstrate more sustained improvements in outcomes. The implementation of dedicated HFUs within health systems should be considered.

What Does "Patient-Centered" Mean? Qualitative Perspectives from Older Adults and Family Caregivers

This study aimed to (1) examine what patient-centeredness means for older adults and family caregivers, and (2) assess circumstances underlying their preference for geriatric care. We conducted separate focus groups with older adults and family caregivers of older adults about health care experiences and expectations and conducted a vignette-based experiment to assess preference for geriatric care. Participants expressed a need for greater skill and empathy and integration of caregivers. They preferred geriatric care to usual primary care with increasing social, health, and healthcare complexity. Distinct needs of older adults should be considered in referral practices to geriatric medicine.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

A mixed methods evaluation of a 4-week geriatrics curriculum in strengthening knowledge and comfort among orthopaedic surgery residents

BACKGROUND

In 2014, the University of Toronto Faculty of Medicine implemented a 4-week "Orthogeriatrics" rotation for orthopaedic surgery residents. We sought to assess the rotation's impact on trainees' knowledge, attitudes, and behaviours toward caring for older adults, and explore areas for improvement.

METHODS

We used a mixed methods concurrent triangulation design. The Geriatrics Clinical Decision-Making Assessment (GCDMA) and Geriatric Attitudes Scale (GAS) compared knowledge, attitudes, and behaviours between trainees who were or were not exposed to the curriculum. Rotation evaluations and semi-structured interviews with trainees and key informants explored learning experiences and the curriculum's impact on resident physician growth and development in geriatric competencies.

RESULTS

Among trainees who completed the GCDMA (n = 19), those exposed to the rotation scored higher in knowledge compared to the unexposed cohort (14.4 ± 2.1 vs. 11.3 ± 2.0, p < 0.01). The following themes emerged from the qualitative analysis of 29 stakeholders: Increased awareness and comfort regarding geriatric medicine competencies, appreciation of the value of orthogeriatric collaboration, and suggestions for curriculum improvement.

CONCLUSIONS

These results suggest that the Orthogeriatrics curriculum strengthens knowledge, behaviour, and comfort towards caring for older adults. Our study aims to inform further curriculum development and facilitate dissemination of geriatric education in surgical training programs across Canada and the world.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study

OBJECTIVE

The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes.

DESIGN

Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year.

SETTING

International (six countries, three continents) multicentre study.

PARTICIPANTS

281 patients aged ≥70 with operatively treated proximal femur fractures.

INTERVENTIONS

Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy.

OUTCOME MEASURES

Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life.

RESULTS

Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002).

CONCLUSIONS

Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02297581.

Octogenarian and Nonagenarians Are at a Higher Risk for Experiencing Adverse 30-Day Outcomes Following ORIF of Ankle Fractures

Introduction:

Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >80 years).

Materials and Methods:

The 2012-2017 American College of Surgeons database was queried for patients undergoing open reduction internal fixation for isolated uni-malleolar, bi-malleolar and tri-malleolar ankle fractures. The study cohort was divided into 3 comparison groups (age <65 years, 65-75 and >80). Multi-variate regression analyzes were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for baseline clinical characteristics and co-morbidity burdens.

Results:

A total of 19,585 patients were included: 5.3% were >80 years, 18.1% were 65-79 years, and 76.6% were <65 years. When compared to the non-geriatric population, individuals >80 years were at a significantly Abstract: higher risk of 30-day wound complications (OR 1.84; p = 0.019), pulmonary complications (OR 3.88; p < 0.001), renal complications (OR 1.96; p = 0.015), septic complications (OR 3.72; p = 0.002), urinary tract infections (OR 2.24; p < 0.001), bleeding requiring transfusion (OR 1.90; p = 0.025), mortality (or 7.44; p < 0.001), readmissions (OR 1.65; p = 0.004) and non-home discharge (OR 13.91; p < 0.001).

Discussion:

Octogenarians undergoing ankle fracture fixation are a high-risk population in need of significant pre-operative surgical and medical optimization. With the majority of patients undergoing non-elective ORIF procedures, it is critical to anticipate potential complications and incorporate experienced geriatric providers early in the surgical management of these patients.

Conclusions:

Octogenarians and nonagenarians are fundamentally distinct and vulnerable age groups with a high risk of complications, readmissions, mortality and non-home discharges compared to other geriatric (65-79 years) and non-geriatric (<65 years) patients. Pre-operative counseling and risk-stratification are essential in this vulnerable patient population.

Functional Status Geriatric Scores: Single-Handed Tools for 30-Day Mortality Risk After Hip Fracture

Background

The 30-day mortality rate after hip fracture surgery has been considered as an indirect indicator of the quality of care. This work aims to appraise the Barthel Index, Katz Index, Lawton-Brody Index, and Physical Red Cross Scale registered in the Comprehensive Geriatric Assessment at admission on the of 30-day death probability after hip fracture surgery.

Methods

Prospective study including 899 hip fracture patients over 65. Bed-ridden, non-surgically treated patients, and high energy trauma or tumoral etiology fractures were excluded. Variables distribution were assessed by χ², U-Mann Whitney and we performed binary logistic regression and equal tailed Jeffreys 95% CI for risk assessment. P<0.05 was considered statistically significant.

Results

We noted a 30-day mortality rate of 5.9%. We related Barthel Index (OR=0.986 [0.975–0.996], p=0.010), Katz Index (OR=1.254 [1.089–1.444], p=0.002), Lawton-Brody Index (OR=0.885 [0.788–0.992], p=0.037), and Physical Red Cross Scale (OR=1.483 [1.094–2.011], p=0.011) with the 30-day mortality of patients after hip fracture surgery. We also validated the Barthel Index inflection point (0–55) (OR_BI(0–55)=2.428 [1.379–4.275], p=0.002) and Katz Index inflection point (A-B) (OR_KI(A-B)=0.493 [0.273–0.891], p=0.019) for the assessment of the highest risked patients.

Conclusion

The geriatric functional status scores would be useful multifunctional and standalone tools in the assessment of hip fracture patients as singly predictors of 30-day mortality.

Prevention and management of osteoporotic fractures by non-physician health professionals: a systematic literature review to inform EULAR points to consider

Objective

To perform a systematic literature review (SLR) about the effect of non-pharmacological interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures.

Methods

Eight clinical questions based on two criteria guided the SLR: (1) adults≥50 years at high risk of osteoporotic fracture and (2) interventions delivered by non-physician health professionals to prevent and manage osteoporotic fractures. Interventions focused on diagnostic procedures to identify risk of falling, therapeutic approaches and implementation strategies. Outcomes included fractures, falls, risk of falling and change in bone mineral density. Systematic reviews and randomised controlled trials were preferentially selected. Data were synthesised using a qualitative descriptive approach.

Results

Of 15 917 records, 43 articles were included. Studies were clinically and methodologically diverse. We identified sufficient evidence that structured exercise, incorporating progressive resistance training delivered to people who had undergone hip fracture surgery, and multicomponent exercise, delivered to people at risk of primary fracture, reduced risk of falling. The effectiveness of multidisciplinary fracture liaison services in reducing refracture rate was confirmed. There was insufficient evidence found to support the effectiveness of nutrients and falls prevention programmes in this patient population.

Conclusion

Despite study heterogeneity, our SLR showed beneficial effects of some interventions delivered by non-physician health professionals and the positive impact of multidisciplinary team working and patient educational approaches to prevent and manage osteoporotic fractures. These results informed a EULAR taskforce that developed points to consider for non-physician health professionals to prevent and manage osteoporotic fractures.

Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database

Hip fractures continue to be one of the most serious and costly injuries suffered by older people globally. This paper describes the development of a national hip fracture audit and summarises the first 6 years of data from the Republic of Ireland. This can help inform care, standards and outcomes of hip fracture patients.

INTRODUCTION

Ireland has one of the highest standardised rates of hip fracture in the world behind northern European countries. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive clinical and organisational improvements in quality and effectiveness of hip fracture care. This paper describes the progression of the IHFD between 2013 and 2018 and identifies trends and areas for improvement.

METHODS

The IHFD is a clinically led, web-based audit, with data collected through the national Hospital Inpatient Enquiry (HIPE) electronic system, the principal source of information from publicly funded acute hospitals in Ireland. Eligible cases are aged ≥ 60 years with hip fracture as defined by IHFD or with other specified hip fracture excluding periprosthetic fractures. As of 2015, all 16 trauma-receiving hospitals within Ireland submitted data. Demographics and adherence to six national quality standards are described.

RESULTS

A total of 17,983 cases were included in the analysis. National coverage has increased from 63% in 2013 to 99% in 2018. Demographic characteristics are unchanged, but higher levels of comorbidity are seen. Internal fixation and hemiarthroplasty are the most common modes of surgical repair with two-thirds of cases receiving spinal rather than general anaesthesia. Increasingly patients are being assessed by a geriatrician (11% in 2013 to 69% in 2018) and receive a bone health assessment (65% in 2013 to 84% in 2018).

CONCLUSION

While some hip fracture standards have improved, further improvements are required to compare favourably internationally. Reduction of surgical delay and ensuring early mobilisation post-operatively are immediate priorities for the IHFD.

Impact of an orthogeriatric collaborative care model for older adults with hip fracture in a community hospital setting

Background

Studies have shown that the incidence of postoperative delirium, the hospital length of stay and time to surgery are reduced when older adults with a hip fracture are cared for by a multidisciplinary team providing comprehensive geriatric assessments. Most of these studies have been conducted in academic centres. We sought to determine if implementation of an orthogeriatric collaborative care model would improve key quality of care metrics in a community hospital setting.

Methods

This retrospective pre- and postintervention single-site study was conducted in a community hospital in Ontario, Canada. We included consecutive patients aged 65 years or older who were admitted for a hip fracture between June 2015 and June 2017. In the intervention period, a new postoperative order set included a referral to a geriatrician for comprehensive geriatric assessment, with direct implementation of recommendations. Primary outcomes were the incidence of postoperative delirium and length of stay. Secondary outcomes included Health Quality Ontario’s quality standards for hip fracture.

Results

A total of 212 consecutive patients (95 in the preintervention group and 117 in the postintervention group) were included in the study. The incidence of postoperative delirium (26.3% v. 26.5%, p = 0.98) and length of stay (interquartile range 4–10 v. 5–10 d, p = 0.32) were similar in the preintervention and postintervention groups. There were improvements (p < 0.001) in the rates of asssessment of mental status, falls and bone health; identification of delirium prevention strategies; prescription of vitamin D or calcium or both; and recommendations for antiresorptive therapy. Despite systemic implementation of the orthogeriatric model, only 74.4% of patients in the postintervention group were seen by a geriatric medicine consultant.

Conclusion

Although the implementation of an orthogeriatric collaborative care model for older adults with a hip fracture did not reduce the incidence of postoperative delirium or length of stay, there were improvements in the rates at which several other key quality standards for hip fracture care were met. Earlier proactive, comprehensive geriatric assessment in a community hospital setting will be the target for further quality improvement initiatives.

Orthogeriatrics prevents functional decline in hip fracture patients: report from two randomized controlled trials

Background

The incidence of hip fractures are expected to increase in the following years. Hip fracture patients have in addition to their fracture often complex medical problems, which constitute a substantial burden on society and health care systems. It is thus important to optimize the treatment of these patients to reduce negative outcomes. The aim of this study was to assess the effect of comprehensive orthogeriatric care (CGC) on basic and instrumental activities of daily living (B-ADL and I-ADL).

Methods

This study is based on two randomized controlled trials; the Oslo Orthogeriatric Trial and the Trondheim Hip Fracture Trial. The two studies were planned in concert, and data were pooled and analyzed using linear mixed models. I-ADL function was assessed by the Nottingham Extended ADL Scale (NEADL) and B-ADL by the Barthel ADL (BADL) at four and twelve months after surgery.

Results

Seven hundred twenty-six patients were included in the combined database, of which 365 patients received OC and 361 patients received CGC. For the primary endpoint, I-ADL at four months was better in the CGC group, with a between-group difference of 3.56 points (95 % CI 0.93 to 6.20, p = 0.008). The between-group difference at 12 months was 4.28 points (95 % CI 1.57 to 7.00, p = 0.002). For B-ADL, between-group difference scores were only statistically significant at 12 months. When excluding the patients living at a nursing home at admission, both I-ADL and B-ADL function was significantly better in the CGC group compared to the OC group at all time points.

Conclusions

Merged data of two randomized controlled trials showed that admitting hip fracture patients to an orthogeriatric care unit directly from the emergency department had a positive effect on ADL up to twelve months after surgery.

Post-hospital care pathway for individuals with hip fracture: what is the optimal setting and rehabilitation intensity? An observational study

PURPOSE

Health systems are using ever-increasing resources on treating hip fractures. Optimal post-hospital care needs to be defined to design an effective care pathway. The aim of the present study was to describe the post-hospital care pathway of individuals with hip fracture and to assess its association with the degree of recovery of independence achieved four months after surgery.

MATERIALS AND METHODS

A prognostic multicentric cohort study was conducted. All patients aged 65 years and over who were admitted with a diagnosis of fragility hip fracture were enrolled. After the hospital discharge, the patients were followed either at an inpatient rehabilitation facility with an intensive or extensive regimen, a nursing home, a long-term care facility or at home. Among the various care pathways, the intensity of rehabilitation differed according to its duration, frequency of sessions, and activities proposed. Primary outcome was the patient's degree of independence achieved four months after surgery, as measured with Activities of Daily Living scale. Several covariates were collected to test the correlation between the different post-hospital care pathways and the recovery of independence.

RESULTS

A total of 923 patients completed the follow-up. A post- hospital rehabilitation pathway was indicated for 88.2% of the patients. The extensive rehabilitation pathway, indicated for 36.7% of the patients, was the most common. The intensive rehabilitation pathway gave better results in terms of independence at four-month follow up, leading to a median ADL score of 1.4 (95% CI 1.0-2.0). The other care pathways did not show significant difference between each other.

CONCLUSIONS

High-intensity rehabilitation was associated to better results in terms of recovering of Activities of Daily Living.IMPLICATIONS FOR REHABILITATIONPost-hospital care pathways that include an intensive rehabilitation treatment should be improved/supported to make them available to a larger number of hip fracture patients.Patient selection criteria for post-hospital rehabilitation pathways should be standardized to optimize available healthcare resources.A cost-effectiveness analysis should be performed to analyze the economic sustainability of each post-hospital care pathway.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.

Predicting 30-Day and 180-Day Mortality in Elderly Proximal Hip Fracture Patients: Evaluation of 4 Risk Prediction Scores at a Level I Trauma Center

This study evaluated the use of risk prediction models in estimating short- and mid-term mortality following proximal hip fracture in an elderly Austrian population. Data from 1101 patients who sustained a proximal hip fracture were retrospectively analyzed and applied to four models of interest: Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), Charlson Comorbidity Index, Portsmouth-POSSUM and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP^®) Risk Score. The performance of these models according to the risk prediction of short- and mid-term mortality was assessed with a receiver operating characteristic curve (ROC). The median age of participants was 83 years, and 69% were women. Six point one percent of patients were deceased by 30 days and 15.2% by 180 days postoperatively. There was no significant difference between the models; the ACS-NSQIP had the largest area under the receiver operating characteristic curve for within 30-day and 180-day mortality. Age, male gender, and hemoglobin (Hb) levels at admission <12.0 g/dL were identified as significant risk factors associated with a shorter time to death at 30 and 180 days postoperative (p < 0.001). Among the four scores, the ACS-NSQIP score could be best-suited clinically and showed the highest discriminative performance, although it was not specifically designed for the hip fracture population.

Efficacy of two integrated geriatric care pathways for the treatment of hip fractures: a cross-cultural comparison

INTRODUCTION

Many studies have focussed on the implementation and outcomes of geriatric care pathways (GCPs); however, little is known about the possible impact of clinical practices on these pathways. A comparison was made between two traumageriatric care models, one Swiss (CH) and one Dutch (NL), to assess whether these models would perform similarly despite the possible differences in local clinical practices.

MATERIALS AND METHODS

This cohort study included all patients aged 70 years or older with a unilateral hip fracture who underwent surgery in 2014 and 2015. The primary outcomes were mortality and complications. Secondary outcomes were time to surgical intervention, hospital length of stay (HLOS), differences in surgical treatment and the number of patients who needed secondary surgical intervention.

RESULTS

A total of 752 patients were included. No differences were seen in mortality at 30 days, 90 days and 1 year post-operatively. In CH, fewer patients had a complicated course (43.5% vs. 51.3%; p = 0.048) and fewer patients were diagnosed with delirium (7.9% vs. 18.3%; p < 0.01). More myocardial infarctions (3.8% vs. 0.4%; p < 0.01) and red blood cell transfusions (27.2% vs. 13.3%; p < 0.01) were observed in CH and HLOS in CH was longer (Mdn difference: - 2; 95% CI - 3 to - 2). Furthermore, a difference in anaesthetic technique was found, CH performed more open reductions and augmentations than NL and surgeons in CH operated more often during out-of-office hours. Also, surgery time was significantly longer in CH (Mdn difference: - 62; 95% CI - 67 to - 58). No differences were seen in the number of patients who needed secondary surgical interventions.

CONCLUSIONS

This cross-cultural comparison of GCPs for geriatric hip fracture patients showed that quality of care in terms of mortality was equal. The difference in complicated course was mainly caused by a difference in delirium diagnosis. Differences were seen in surgical techniques, operation duration and timing. These clinical practices did not influence the outcome.

Evaluating the need for an integrated geriatric service in older general surgery patients

BACKGROUND

Despite the success of an orthogeriatric model in improving outcomes of older patients, there is a paucity of evidence in general surgical disciplines. The aim of this project was to assess the viability of acute kidney injury (AKI) as an indicator of the care of older patients admitted under general surgery.

METHODS

A retrospective review of the medical records of patients aged 75 years and older admitted under general surgery between 1 July 2015 and 30 June 2018 at the Royal Hobart Hospital was conducted. Twenty randomly selected cases were reviewed by an expert panel to assess the preventability of AKI.

RESULTS

Of 314 patients, the most common diagnosis was small bowel obstruction. Less than half of all patients underwent a procedural intervention. There were 32 (10%) cases of AKI; 13 (4%) had pre-hospital and 19 (6%) had inpatient. Diabetes and bowel ischaemia were over-represented in patients with an AKI, otherwise there was no significant difference between the groups. Patients with an AKI were significantly more likely to die, require an unplanned intensive care unit admission and less likely to return to their original residence. Overall, the expert panel agreed that the AKI was foreseeable and mitigable.

CONCLUSION

Our patients presented with diagnoses that often did not require surgical intervention but not infrequently experienced medical complications. These patients may benefit from a shared model of care and AKI could be a useful indicator to measure the efficiency of this service.

External validation of the Almelo Hip Fracture Score, a prediction model for early mortality following hip fracture surgery

PURPOSE

Early mortality (< 30 days) in hip fracture patients is as high as 9.6%. Several risk assessment tools have been developed to identify patients at high risk for early mortality. Among them, the Almelo Hip Fracture Score (AHFS) was developed recently and showed promising results. Until now, this tool has not been validated; therefore, we aim to perform an external validation of the AHFS.

METHODS

On admission, AHFS variables were prospectively collected. The prospectively collected data were used retrospectively to externally validate the AHFS in a cohort of hip fracture patients that were admitted to a hospital in Delft (Delft cohort). The AHFS score was retrospectively calculated for all hip fracture patients meeting the inclusion criteria. The characteristics of the Delft Cohort, AHFS score, sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve were calculated and compared to the original Almelo cohort, in which the AHFS was developed.

RESULTS

422 patients of 70 years and older were included. Mortality within 30 days was 7.6% and similar to the 7.5% observed in the Almelo cohort. For the high-risk cut-off point, specificity was 95.4% in the Delft Cohort vs. 92.5% in the Almelo Cohort, and sensitivity for the low-risk cut-off point was 75.9 vs. 78.1% in the Almelo Cohort. The area under the ROC curve was 0.70 (95% CI 0.60-0.79) compared to 0.82 in the Almelo cohort.

CONCLUSIONS

The validity of the score was acceptable and comparable to the values in the Almelo cohort. This score might be used to identify patients at high risk for early mortality.

Implementing a Geriatric Fracture Program in a Mixed Practice Environment Reduces Total Cost and Length of Stay

Introduction:

Geriatric-orthopaedic co-management models can improve patient outcomes. However, prior reports have been at large academic centers with “closed” systems and an inpatient geriatric service. Here we describe a Geriatric Fracture Program (GFP) in a mixed practice “pluralistic” environment that includes employed academic faculty, private practice physicians, and multiple private hospitalist groups. We hypothesized GFP enrollment would reduce length of stay (LOS), time to surgery (TTS), and total hospital costs compared to non-GFP patients.

Materials and Methods:

A multidisciplinary team was created around a geriatric Nurse Practitioner (NP) and consulting geriatrician. Standardized geriatric focused training programs and electronic tools were developed based on best practice guidelines. Fracture patients >65 years old were prospectively enrolled from July 2018 – June 2019. A trained biostatistician performed all statistical analyses. A p < 0.05 was considered significant.

Results:

564 operative and nonoperative fractures in patients over 65 were prospectively followed with 153 (27%) enrolled in the GFP and 411 (73%) admitted to other hospitalists or their primary care provider (non-GFP). Patients enrolled in the GFP had a significantly shorter median LOS of 4 days, compared to 5 days in non-GFP patients (P < 0.001). There was a strong trend towards a shorter median TTS in the GFP group (21.5 hours v 25 hours, p = 0.066). Mean total costs were significantly lower in the GFP group ($25,323 v $29085, p = 0.022)

Discussion:

Our data shows that a geriatric-orthopaedic co-management model can be successfully implemented without an inpatient geriatric service, utilizing the pre-existing resources in a complex environment. The program can be expanded to include additional groups to improve care for entire geriatric fracture population with significant anticipated cost savings.

Conclusions:

With close multidisciplinary team work, a successful geriatric-orthopaedic comanagement model for geriatric fractures can be implemented in even a mixed practice environment without an inpatient geriatrics service.

Characteristics and Outcomes of Hip Fracture Patients Hospitalized in an Orthogeriatric Unit Versus an Orthopedic Department: A Retrospective Cohort Study

Introduction:

Hip fractures are a significant health risk in older adults and a major cause of morbidity, functional decline and mortality. Our aim was to compare clinical outcomes of older patients hospitalized in an ortho-geriatric (OG) unit to those hospitalized in an orthopedic department (OD) for surgical treatment of a hip fracture.

Methods:

A retrospective cohort study of hip fractured patients hospitalized between 2015-2016 in a single tertiary university-affiliated medical center. Included were patients aged 65 and older who had undergone hip fracture surgery and were admitted to either a geriatric or orthopedic ward.

Results:

441 patients met the inclusion criteria (195 in the OG unit, 246 in the OD); 257 were transferred to an affiliated geriatric center hospital (107 from the OG unit and 127 from the OD) for rehabilitation. Patients in the OG unit were older, more cognitively and functionally impaired and with more comorbidities. The 1-year mortality rate was significantly lower in the OD group (OR 0.32, CI 95% 0.19-0.53, p < 0.001), however, after propensity matching, the 30-day and 1 year mortality rates were similar in both groups. No difference was found in the rehabilitation length of stay between the groups. The functional independence measure improvement was similar in both groups, with a non-significant trend toward better functional improvement among OG unit patients.

Conclusions:

Despite the higher complexity of patients, worse baseline functional capacity in the OG unit, improvement after rehabilitation was similar in both groups. These results demonstrate the advantages of the OG unit in treating and stabilizing frail older adults, thus maximizing their chances for a successful recovery after hip fractures.

Level of Evidence:

Level IV

Protocol for evaluation of perioperative risk in patients aged over 75 years: Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT study)

BACKGROUND

With the extended life expectancy of the Chinese population and improvements in surgery and anesthesia techniques, the number of aged patients undergoing surgery has been increasing annually. However, safety, effectiveness, and quality of life of aged patients undergoing surgery are facing major challenges. In order to standardize the perioperative assessment and procedures, we have developed a perioperative evaluation and auxiliary decision-making system named "Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT)".

METHODS

We will conduct a perioperative risk evaluation and targeted intervention, with follow-ups at 1, 3, and 6 months after surgery. The primary objective of the study is to evaluate the effectiveness of the "Aged Patient Perioperative Longitudinal Evaluation-Multiple Disciplinary Trial Path" (hereinafter referred to as the APPLE-MDT path) in surgical decision-making for aged patients (≥75 years) undergoing elective surgery under non-local anesthesia in the operating room. The secondary objectives of the study are to evaluate the postoperative outcome and health economics of the APPLE-MDT path applied to the surgical decision-making of aged patients (≥75 years) undergoing elective surgery under non-local anesthesia and to optimize intervention strategies for aged patients undergoing surgery to reduce the occurrence of postoperative complications and improve the quality of life after surgery.

DISCUSSION

It is necessary to formulate a reliable, effective, and concise evaluation tool, which can effectively predict the perioperative complications and mortality of aged patients, support targeted intervention strategies, and allow for a more comprehensive risk and benefit analysis, thereby forming an effective senile perioperative surgery management path. It is expected that the implementation of this protocol can reduce the occurrence of postoperative complications, improve the postoperative quality of life, shorten hospital stay, reduce hospitalization expenses, reduce social burden, and allow the elderly to have a good quality of life after surgery.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800020363 , Registered 15 December 2018.

Considerations in Surgical Management of Gastrointestinal Cancer in Older Patients

PURPOSE OF REVIEW

The goal of this manuscript is to present new and thought-provoking information related to the surgical care of older patients. We focused on four main areas including communication, surgical pathways, the care of emergency surgery patients, and functional recovery and quality of life. We sought to answer how these areas have evolved, affecting the care of older patients.

RECENT FINDINGS

Older patients with cancer present particular challenges in relation to communication, goals, surgical treatment, and post-surgical outcomes. Communication should be clear early and during the treatment course. A multidisciplinary, multimodality, multi-phase pathway can be utilized to improve the postoperative outcomes of older patients with cancer. Functional recovery and quality of life can and should be measured in this population. Communication is complicated in cancer patients, which is made more complex with advancing age. Communication is the cornerstone of the treatment of older patients. Future research should focus on interventions to improve communication and measure quality of life and functional recovery metrics.

Textbook process as a composite quality indicator for in-hospital hip fracture care

Individual process indicators often do not enable the benchmarking of hospitals and often lack an association with outcomes of care. The composite hip fracture process indicator, textbook process, might be a tool to detect hospital variation and is associated with better outcomes during hospital stay.

PURPOSE

The aim of this study was to determine hospital variation in quality of hip fracture care using a composite process indicator (textbook process) and to evaluate at patient level whether fulfilment of the textbook process indicator was associated with better outcomes during hospital stay.

METHODS

Hip fracture patients aged 70 and older operated in five hospitals between 1 January 2018 and 31 December 2018 were included. Textbook process for hip fracture care was defined as follows: (1) assessment of malnutrition (2) surgery within 24 h, (3) orthogeriatric management during admission and (4) operation by an orthopaedic trauma certified surgeon. Hospital variation analysis was done by computing an observed/expected ratio (O/E ratio) for textbook process at hospital level. The expected ratios were derived from a multivariable logistic regression analysis including all relevant case-mix variables. The association between textbook process compliance and in-hospital complications and prolonged hospital stay was determined at patient level in a multivariable logistic regression model, with correction for patient, treatment and hospital characteristics. In-hospital complications were anaemia, delirium, pneumonia, urinary tract infection, in-hospital fall, heart failure, renal insufficiency, pulmonary embolism, wound infection and pressure ulcer.

RESULTS

Of the 1371 included patients, 753 (55%) received care according to textbook process. At hospital level, the textbook compliance rates ranged from 38 to 76%. At patient level, textbook process compliance was significantly associated with fewer complications (38% versus 46%) (OR 0.66, 95% CI 0.52-0.84), but not with hospital stay (median length of hospital stay was 5 days in both groups) (OR 1.01, 95% CI 0.78-1.30).

CONCLUSION

The textbook process indicator for hip fracture care might be a tool to detect hospital variation. At patient level, this quality indicator is associated with fewer complications during hospital stay.

Coronavirus disease 2019 (COVID-19) markedly increased mortality in patients with hip fracture - A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to evaluate the prevalence of coronavirus disease 2019 (COVID-19) and its impact on mortality in patients with hip fracture.

METHODS

We performed a systematic literature search in PubMed, Cochrane Central Database, and medRvix from inception up to July 13, 2020 on research articles that enrolled hip fracture patients who had information on COVID-19 and clinically validated definition of death.

RESULTS

A total of 984 participants from 6 studies were included in our study. The pooled prevalence of COVID-19 was 9% [95% CI: 7-11%]. The mortality rate in patients with concomitant hip fracture and COVID-19 was found to be 36% (95% CI: 26-47%), whereas the mortality rate in hip fracture without COVID-19 is 2% (95% CI: 1-3%). Meta-analysis showed that COVID-19 was associated with a seven-fold increase in risk (RR 7.45 [95% CI: 2.72, 20.43], p < 0.001; I2: 68.6%) of mortality in patients with hip fracture. Regression-based Harbord's test showed no indication of small-study effects (p = 0.06).

CONCLUSION

The present meta-analysis showed that COVID-19 increased the risk of mortality in patients with hip fracture.

TRIAL REGISTRATION

This study is registered with PROSPERO, July 21, 2020, number CRD42020199618. Available from https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020199618.

2019 EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older

OBJECTIVE

To establish European League Against Rheumatism (EULAR) points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older.

METHODS

Points to consider were developed in accordance with EULAR standard operating procedures for EULAR-endorsed recommendations, led by an international multidisciplinary task force, including patient research partners and different health professionals from 10 European countries. Level of evidence and strength of recommendation were determined for each point to consider, and the mean level of agreement among the task force members was calculated.

RESULTS

Two overarching principles and seven points to consider were formulated based on scientific evidence and the expert opinion of the task force. The two overarching principles focus on shared decisions between patients and non-physician health professionals and involvement of different non-physician health professionals in prevention and management of fragility fractures. Four points to consider relate to prevention: identification of patients at risk of fracture, fall risk evaluation, multicomponent interventions to prevent primary fracture and discouragement of smoking and overuse of alcohol. The remaining three focus on management of fragility fractures: exercise and nutritional interventions, the organisation and coordination of multidisciplinary services for post-fracture models of care and adherence to anti-osteoporosis medicines. The mean level of agreement among the task force for the overarching principles and the points to consider ranged between 8.4 and 9.6.

CONCLUSION

These first EULAR points to consider for non-physician health professionals to prevent and manage fragility fractures in adults 50 years or older serve to guide healthcare practice and education.

Factors associated with optimal patient outcomes after operative repair of isolated hip fractures in the elderly

BACKGROUND

Increased time to operative intervention is associated with a greater risk of mortality and complications in adults with a hip fracture. This study sought to determine factors associated with timeliness of operation in elderly patients presenting with an isolated hip fracture and the influence of surgical delay on outcomes.

METHODS

Trauma quality collaborative data (July 2016 to June 2019) were analyzed. Inclusion criteria were patients ≥65 years with an injury mechanism of fall, Abbreviated Injury Scale (AIS) 2005 diagnosis of hip fracture, and AIS extremity ≤3. Exclusion criteria included AIS in other body regions >1 and non-operative management. We examined the association of demographic, hospital, injury presentation, and comorbidity factors on a surgical delay >48 hours and patient outcomes using multivariable regression analysis.

RESULTS

10 182 patients fit our study criteria out of 212 620 patients. Mean age was 82.7±8.6 years and 68.7% were female. Delay in operation >48 hours occurred in 965 (9.5%) of patients. Factors that significantly increased mortality or discharge to hospice were increased age, male gender, emergency department hypotension, functionally dependent health status (FDHS), advanced directive, liver disease, angina, and congestive heart failure (CHF). Delay >48 hours was associated with increased mortality or discharge to hospice (OR 1.52; 95% CI 1.13 to 2.06; p<0.01). Trauma center verification level, admission service, and hip fracture volume were not associated with mortality or discharge to hospice. Factors associated with operative delay >48 hours were male gender, FDHS, CHF, chronic renal failure, and advanced directive. Admission to the orthopedic surgery service was associated with less incidence of delay >48 hours (OR 0.43; 95% CI 0.29 to 0.64; p<0.001).

DISCUSSION

Hospital verification level, admission service, and patient volume did not impact the outcome of mortality/discharge to hospice. Delay to operation >48 hours was associated with increased mortality. The only measured modifiable characteristic that reduced delay to operative intervention was admission to the orthopedic surgery service.

LEVEL OF EVIDENCE

III.

Exploring the roles of advanced practice nurses in the care of patients following fragility hip fracture: A systematic review

AIM

This study aimed to explore the role and impact of advanced practice nurses (APNs) in care of patients following fragility hip fracture by systematically reviewing the available evidence.

REVIEW DESIGN

Systematic review.

DATA SOURCES

A search of the databases Ovid Medline, CINAHL, Embase, Emcare, Cochrane Library, and Google Scholar was conducted from January-February 2019.

METHOD

This systematic review adhered to The PRISMA Statement. Study selection was managed using the Covidence software platform and quality was assessed using JBI Critical appraisal tools. Studies included adults >18 years and described the role and impact of APNs in care of patients following fragility hip fracture on clinical and non-clinical outcomes.

RESULTS

There were 19 papers identified that met the inclusion/exclusion criteria. Quality was graded as moderate to low risk of bias. Six characteristics of APNs were identified: (1) coordination; (2) collaboration; (3) education; (4) assessment, investigation and treatment recommendations; (5) discharge planning, support and follow up; and (6) documentation. Overall mortality and LOS improved when characteristics of the APN role were present.

CONCLUSION

Key findings from this systematic review showed: (1) The APN title and role are not clearly defined, but characteristics of the APN role are evident; (2) characteristics of APNs promote the delivery of best practice hip fracture care and have a positive impact on mortality and LOS; and (3) innovative service delivery models involving APNs should be considered to address future projections of hip fracture rates and improve outcomes.

IMPACT

This systematic review provides evidence of the role characteristics of APNs in fragility hip fracture and the impact of the role on outcomes. Findings from this research could be used to develop service delivery models using APNs to care for patients following fragility hip fracture and to inform practice where APN roles may improve outcomes for other patient cohorts.

Implementation of an electronic care pathway for hip fracture patients: a pilot before and after study

BACKGROUND

Care pathways are generally paper-based and can cause communication failures between multidisciplinary teams, potentially compromising the safety of the patient. Computerized care pathways may facilitate better communication between clinical teams. This study aimed to investigate whether an electronic care pathway (e-pathway) reduces delays in surgery and hospital length of stay compared to a traditional paper-based care pathway (control) in hip fracture patients.

METHODS

A single-centre evaluation with a retrospective control group was conducted in the Orthogeriatric Ward, Nepean Hospital, New South Wales, Australia. We enrolled patients aged > 65 years that were hospitalized for a hip fracture in 2008 (control group) and 2012 (e-pathway group). The e-pathway provided the essential steps in the care of patients with hip fracture, including examinations and treatment to be carried out. Main outcome measures were delay in surgery and hospital length of stay; secondary outcomes were in-hospital mortality and discharge location.

RESULTS

A total of 181 patients were enrolled in the study (129 control; 54 e-pathway group). There was a significant reduction in delay to surgery in the e-pathway group compared to control group in unadjusted (OR = 0.19; CI 0.09-0.39; p < 0.001) and adjusted (OR = 0.22; CI 0.10-0.49; p < 0.001) models. There were no significant differences between groups for length of stay (median 11 vs 12 days; p = 0.567), in-hospital mortality (1 vs 7 participants; p = 0.206) or discharge location (p = 0.206).

CONCLUSIONS

This pilot study suggests that, compared to a paper-based care pathway, implementation of an e-pathway for hip fracture patients results in a reduction in total number of delays to surgery, but not hospital length of stay. Further evaluation is warranted using a larger cohort investigating both clinical and patient-reported outcome measures.

The Impact of Interdisciplinary Care on Cost Reduction in a Geriatric Trauma Population

The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS).

Development and Internal Validation of a Prediction Model for In-Hospital Mortality in Geriatric Patients With a Hip Fracture

OBJECTIVE

To develop and validate a prediction model for in-hospital mortality in patients with hip fracture 85 years of age or older undergoing surgery.

DESIGN

A multicenter prospective cohort study.

SETTING

Six Dutch trauma centers, level 2 and 3.

PARTICIPANTS

Patients with hip fracture 85 years of age or older undergoing surgery.

INTERVENTION

Hip fracture surgery.

MAIN OUTCOME MEASUREMENTS

In-hospital mortality.

RESULTS

The development cohort consisted of 1014 patients. In-hospital mortality was 4%. Age, male sex, American Society of Anesthesiologists classification, and hemoglobin levels at presentation were independent predictors of in-hospital mortality. The bootstrap adjusted performance showed good discrimination with a c-statistic of 0.77.

CONCLUSION

Age, male sex, higher American Society of Anesthesiologists classification, and lower hemoglobin levels at presentation are robust independent predictors of in-hospital mortality in patients with geriatric hip fracture and were incorporated in a simple prediction model with good accuracy and no lack of fit.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Predictive Value of Comprehensive Geriatric Assessment on Early Postoperative Complications Following Lumbar Spinal Stenosis Surgery: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the predictive value of comprehensive geriatric assessment (CGA) for early postoperative complications in elderly patients (aged 65 years or older) following lumbar spinal stenosis surgery.

SUMMARY OF BACKGROUND DATA

CGA is a multidisciplinary evaluation modality proven to be effective in various fields of geriatrics. However, limited evidence exists on the effectiveness of CGA in lumbar spinal stenosis patients in the literature.

METHODS

We prospectively enrolled consecutive patients who were at least 65 years' old and were scheduled to undergo elective surgery for lumbar spinal stenosis. One day before the operation, multidomain CGA was performed on the patient's functional status, comorbidities, nutrition, cognition, and psychological status. Patients with deficits in three or more CGA domains were defined as frail. The occurrence of postoperative complications (Clavien and Dindo grade 2 or higher) within 30 days after the surgery was assessed as the outcome. The predictive value of CGA was evaluated using crosstab and logistic regression analysis and compared to that of other risk stratification systems, including modified Frailty Index-5, -11, and American Society of Anesthesiologists Physical Classification System.

RESULTS

A total of 261 patients were included in the study, and 25 (9.6%) patients were assigned to the "frail" group. There were 27 (10.3%) patients with a postoperative complication (general: n = 20, 7.7%, surgical: n = 7, 2.7%) within postoperative 30 days. Patients with a complication showed significantly more deficits on preoperative CGA than those without complications (P = 0.004). On multivariate logistic regression analysis, frailty based on CGA (odds ratio = 3.51, P = 0.031) and the modified Frailty Index-11 (odds ratio = 3.13, P = 0.038) were associated with the occurrence of general complications.

CONCLUSION

Frailty based on CGA was significantly associated with early general complications following surgery for lumbar spinal stenosis in patients older than 65 years.

LEVEL OF EVIDENCE

2.

The Current and Future Challenges of Hip Fracture Management in Malaysia

By 2050, it is predicted that six million hip fractures will occur each year of which the majority will happen in Asia. Malaysia is not spared from this predicted rise and its rate of increase will be one of the highest in this region. Much of this is driven by our unprecedented growth in the number of older people. Characteristics of individuals with hip fractures in Malaysia mirror what has been reported in other countries. They will be older multimorbid people who were already at risk of falls and fractures. Outcomes were poor with at least a quarter do not survive beyond 12 months and in those that do survive have limitation in their mobility and activities of daily living. Reviewing how these fractures are managed and incorporating new models of care, such as orthogeriatric care, could address these poor outcomes. Experts have warned of the devastating impact of hip fracture in Malaysia and that prompt action is urgently required. Despite that, there remains no national agenda to highlight the need to improve musculoskeletal health in the country.

Risk Factors for Failure to Rescue in Myocardial Infarction after Noncardiac Surgery: A Cohort Study

BACKGROUND

Compared to other perioperative complications, failure to rescue (i.e., death after suffering a complication) is highest after perioperative myocardial infarction (a myocardial infarction that occurs intraoperatively or within 30 days after surgery). The purpose of this study was to identify patient and surgical risk factors for failure to rescue in patients who have had a perioperative myocardial infarction.

METHODS

Individuals who experienced a perioperative myocardial infarction after noncardiac surgery between 2012 and 2016 were identified from the American College of Surgeons (Chicago, Illinois) National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue. Subgroup and sensitivity analyses evaluated the robustness of primary findings.

RESULTS

The authors identified 1,307,884 individuals who had intermediate to high-risk noncardiac surgery. A total of 8,923 (0.68%) individuals had a perioperative myocardial infarction, of which 1,726 (19.3%) experienced failure to rescue. Strongest associations (adjusted odds ratio greater than 1.5) were age 85 yr or older (2.52 [95% CI, 2.05 to 3.09] vs. age younger than 65 yr), underweight body mass index (1.53 [95% CI, 1.17 to 2.01] vs. normal body mass index), American Society of Anesthesiologists class IV (1.76 [95% CI, 1.33 to 2.31] vs. class I or II) and class V (3.48 [95% CI, 2.20 to 5.48] vs. class I or II), and presence of: ascites (1.81 [95% CI, 1.15 to 2.87]), disseminated cancer (1.54 [95% CI, 1.18 to 2.00]), systemic inflammatory response syndrome (1.55 [95% CI, 1.26 to 1.90]), sepsis (1.75 [95% CI, 1.39 to 2.20]), septic shock (1.79 [95% CI, 1.34 to 2.37]), and dyspnea at rest (1.94 [95% CI, 1.32 to 2.86]). Patients who had emergency surgery, high-risk procedures, and postoperative complications were at higher risk of failure to rescue.

CONCLUSIONS

Routinely identified patient and surgical factors predict risk of failure to rescue after perioperative myocardial infarction.

Geriatric Assessment, Not ASA Physical Status, Is Associated With 6-Month Postoperative Survival in Patients With Cancer Aged ≥75 Years

BACKGROUND

The American Society of Anesthesiologists physical status (ASA PS) classification system is the most common method of assessing preoperative functional status. Comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool for preoperative assessment of older adults. The goal of this study was to assess the correlation between ASA classification and CGA deficits among oncogeriatric patients and to determine the association of each with 6-month survival.

PATIENTS AND METHODS

Oncogeriatric patients (aged ≥75 years) who underwent preoperative CGA in an outpatient geriatric clinic at a single tertiary comprehensive cancer center were identified. All patients underwent surgery, with a hospital length of stay (LOS) ≥1 day and at least 6 months of follow-up. ASA classifications were obtained from preoperative anesthesiology notes. Preoperative CGA scores ranged from 0 to 13. Six-month survival was assessed using the Social Security Death Index.

RESULTS

In total, 81 of the 980 patients (8.3%) included in the study cohort died within 6 months of surgery. Most patients were classified as ASA PS III (85.4%). The mean number of CGA deficits for patients with PS II was 4.03, PS III was 5.15, and PS IV was 6.95 (P<.001). ASA classification was significantly associated with age, preoperative albumin level, hospital LOS, and 30-day intensive care unit (ICU) admissions. On multivariable analysis, 6-month mortality was associated with number of CGA deficits (odds ratio [OR], 1.14 per each unit increase in CGA score; P=.01), 30-day ICU admissions (OR, 2.77; P=.003), hospital LOS (OR, 1.03; P=.02), and preoperative albumin level (OR, 0.36; P=.004). ASA classification was not associated with 6-month mortality.

CONCLUSIONS

Number of CGA deficits was strongly associated with 6-month mortality; ASA classification was not. Preoperative CGA elicits critical information that can be used to enhance the prediction of postoperative outcomes among older patients with cancer.

Orthogeriatric Trauma Unit Improves Patient Outcomes in Geriatric Hip Fracture Patients

Introduction:

An aging population in developed countries has increased the number of osteoporotic hip fractures and will continue to grow over the next decades. Previous studies have investigated the effect of integrated orthogeriatric trauma units and care model on outcomes of hip fracture patients. Although all of the models perform better than usual care, there is no conclusive evidence which care model is superior. More confirmative studies reporting the efficacy of orthogeriatric trauma units are needed. The objective of this study was to evaluate outcomes of hip fracture patients admitted to the hospital before and after implementation of an orthogeriatric trauma unit.

Materials and methods:

This retrospective cohort study was conducted at a level 2 trauma center between 2016 and 2018. Patients aged 70 years or older with a hip fracture undergoing surgery were included to evaluate the implementation of an orthogeriatric trauma unit. The main outcomes were postoperative complications, patient mortality, time spent at the emergency department, time to surgery, and hospital length of stay.

Results:

A total of 806 patients were included. After implementation of the orthogeriatric trauma unit, there was a significant decrease in postoperative complications (42% vs. 49% in the historical cohort, p = 0.034), and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly less missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908, p = 0.011) and a lower chance of 1-year mortality (OR 0.656, 95% CI 0.450-0.957, p = 0.029).

Conclusions:

This study showed that implementation of an orthogeriatric trauma unit leads to a decrease in postoperative complications, 1-year mortality, and time spent at the emergency department, while also improving the quality of data registration for clinical studies.

Level of Evidence:

Level III.

Hip Fracture Prevention in Osteoporotic Elderly and Cancer Patients: An On-Line French Survey Evaluating Current Needs

Background and objectives: Hip fracture is a major public health issue. Those fractures lead to high costs and a decrease in quality of life. A national French survey was conducted, with the objectives to firstly assess the current management of hip fracture and its prevention, both in the osteoporotic and cancer settings, and secondly to evaluate the opinions of physicians on the potential use of minimally invasive implantable devices to prevent hip fracture in alternative of surgery. Materials and methods: This national survey was conducted in France between April and July 2017. Questionnaires were sent to orthopedic surgeons, interventional radiologists, oncologists, and rheumatologists. Completed questionnaires were analyzed and compared according to two indications: orthopedics-traumatology and oncology. Factors associated with these responses were assessed using univariable analyses, based on chi-square tests or an exact Fisher test, as appropriate. Results: A total of 182 questionnaires were completed and further analyzed. Physicians have highlighted the need for a low re-fracture rate and to improve life expectancy for more than 1 year (50% for responders of the orthopedics-traumatology questionnaire and 80% for the responders interested in both indications), as well as quality of life (12.5% and 31%, respectively), but with no significant differences in the oncologic indication. Most of the experts were willing to use or prescribe implantable devices for prevention (63% in orthopedics-traumatology and 93% in oncology), although limited clinical experience (54 and 58%) and surgical risk (around 30% in each indication) were considered as limits. Conclusions: Prevention of hip fracture remains a concern for physicians. More clinical experience with implantable devices, in particular in cancer patients, is needed, but implemented in a strategy to maximize patient recovery while reducing costs.

Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery?

Introduction

This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery.

Materials and Methods

Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk.

Results

Six hundred eleven patients met inclusion criteria with mean age 81.1 ± 10.5 years. Injuries occurred mainly secondary to low-energy mechanisms (97.9%). Median time to surgery (31.9 hours overall) was significantly associated with STTGMA stratification (P = .002). Moderate-risk patients had 33% longer (P = .019) and high-risk patients had 28% longer time to surgery (P = .041) compared to minimal risk patients. Delay to surgery (26.4% overall) was significantly associated with STTGMA stratification (P = .015). Low-risk patients had 2.14× higher odds (P = .009), moderate-risk patients had 2.70× higher odds (P = .001), and high-risk patients had 2.18× higher odds of delay to surgery (P = .009) compared to minimal risk patients. High-risk patients experienced higher 30-day mortality compared to minimal (P < .001), low (P = .046), and moderate-risk patients (P = .046).

Discussion

Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality.

Conclusion

Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients.

Level of Evidence

Prognostic Level III.

Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer

IMPORTANCE

Collaboration between geriatricians and surgeons in the perioperative treatment of older patients has been associated with improved outcomes in several nononcologic specialties. Similar associations may be possible among older patients with cancer.

OBJECTIVE

To investigate the associations of geriatric comanagement of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study assessed outcomes of patients who received geriatric comanaged care vs those who did not using multivariable logistic regression analysis, with 90-day mortality as the outcome and geriatric comanagement of care as the main variable, with adjustment for age, sex, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index score, preoperative albumin level, operative time, and estimated blood loss. A similar model was used to assess the association of geriatric comanagement with adverse surgical events, defined as any major complication, readmission, or emergency department visit within 30 days. Patients aged 75 years and older who underwent an elective surgical procedure with a hospital stay of at least 1 day at a single tertiary-care cancer center between February 2015 and February 2018 were included. Data were analyzed from January to July 2019.

EXPOSURES

Postoperative care comanaged by the geriatrics service and surgical service (geriatric comanagement group) vs by the surgical service only (surgical service group).

MAIN OUTCOMES AND MEASURES

90-day mortality, adverse surgical events, and use of supportive care services.

RESULTS

Of 1892 patients included, 1020 (53.9%) received geriatric comanagement of care; these patients, compared with those who received care managed by the surgery service only, were older (mean [SD] age, 81 [4] years vs 80 [4] years; P < .001), had longer operative time (mean [SD], 203 [146] minutes vs 138 [112] minutes; P < .001), and longer length of stay (median [interquartile range], 5 [3-8] days vs 4 [2-7] days; P < .001). There were no differences in the proportions of men (488 [47.8%] men vs 450 [51.6%] men; P = .11). Adverse surgical events were not significantly different between groups (odds ratio, 0.93 [95% CI, 0.73-1.18]; P = .54). However, the adjusted probability of death within 90 days after surgical treatment was 4.3% for the geriatric comanagement group vs 8.9% for the surgical service group (difference, 4.6% [95% CI, 2.3%-6.9%]; P < .001). Additionally, compared with patients who received postoperative care management from the surgery service only, a higher proportion of patients in the geriatric comanagement group received inpatient supportive care services, including physical therapy (555 patients [63.6%] vs 820 patients [80.4%]; P < .001), occupational therapy (220 patients [25.2%] vs 385 patients [37.7%]; P < .001), speech and swallow rehabilitation (42 patients [4.8%] vs 86 patients [8.4%]; P = .002), and nutrition services (637 patients [73.1%] vs 803 patients [78.7%]; P = .004).

CONCLUSIONS AND RELEVANCE

This cohort study found that geriatric comanagement was associated with significantly lower 90-day postoperative mortality among older patients with cancer. These findings suggest that such patients may benefit from geriatric comanagement, which could improve their ability to survive adverse postoperative events.

Effect of COVID-19 on a rural orthopaedic hip fracture service

AIMS

Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures.

METHODS

We reviewed our prospectively maintained trust database and National Hip Fracture Database records for the months of March and April between the years 2016 and 2020. Our assessment included fracture pattern (intrascapular vs extracapsular hip fracture), treatment intervention, length of stay and mortality.

RESULTS

We treated 288 patients during March and April between 2016 and 2020, with a breakdown of 55, 58, 53, 68, and 54 from 2016 to 2020 respectively. Fracture pattern distribution in the pre-COVID-19 years of 2016 to 2019 was 58% intracapsular and 42% extracapsular. In 2020 (COVID-19 period) the fracture patterns were 65% intracapsular and 35% extracapsular. Our mean length of stay was 13.1 days (SD 8.2) between 2016 to 2019, and 5.0 days (6.3) days in 2020 (p < 0.001). Between 2016 and 2019 we had three deaths in hip fracture patients, and one death in 2020. Hemiarthroplasty and dynamic hip screw fixation have been the mainstay of operative intervention across the five years and this has continued in the COVID-19 period. We have experienced a rise in conservatively managed patients; ten in 2020 compared to 14 over the previous four years.

CONCLUSION

There has not been a reduction in the number of hip fractures during COVID-19 period compared to the same time period over previous years. In our experience, there has been an increase in conservative treatment and decreased length of stay during the COVID -19 period.Cite this article: Bone Joint Open 2020;1-8:500-507.

Hip fractures in the elderly Chilean population: a projection for 2030

Using national databases, we projected the magnitude of hip fractures among the elderly Chilean population by 2030. Hip fractures will increase by 27.5% from 2018 to 9862 cases (95% CI = 8760 to 10,965). The most substantial growth is expected to occur in patients older than 80 years of age.

INTRODUCTION

There is scarce information regarding the magnitude of hip fractures that will be observed in Latin American countries in the near future. The aim of this study is to project the volume of hip fractures in the elderly Chilean population by the year 2030.

METHODS

The database of the Chilean Department of Statistics and Health Information, which includes all hospital discharges within Chile, was employed to evaluate the volume of hip fractures observed from 2012 to 2018 in the elderly population (≥ 65 years old). The annual incidence was determined by combining the volume of fractures with census data. Linear regression analysis was performed to determine the projected volume of hip fractures for 2030.

RESULTS

For 2030, hip fractures among the elderly population are projected to grow 27.5% (R² = 0.92) to 9862 cases (95% CI = 8760 to 10,965). In the group from 65 to 79 years old, hip fractures are expected to grow 21.6% (R² = 0.87) to 3046 cases (95% CI = 2686 to 3405). In patients ≥ 80 years of age, hip fractures are expected to grow 30.1% (R² = 0.9) to 6817 cases (95% CI = 5889 to 7744).

CONCLUSIONS

A substantial growth in the volume of hip fractures is expected for the next decade among the elderly Chilean population, especially in patients ≥ 80 years of age. A national healthcare strategy should consider efforts to mitigate the impact of the future burden related to patients' care.

Preoperative simplified geriatric assessment in planned hip and knee arthroplasty

INTRODUCTION

Hip and knee arthroplasties are the most common planned orthopedic surgical procedures in older persons. It would be useful to identify frailties before surgery to improve the outcome of older patients.

PURPOSE

The objective of this work was to identify the criteria of a simplified comprehensive geriatric assessment (mini-CGA) that were associated with unplanned hospital readmission and postoperative complications within 3 months after the planned hip and/or knee arthroplasty in patients ≥ 65 years.

METHODS

This prospective study was carried out in the orthopedic department of Marseille University Hospital from January to May 2019. A mini-CGA was performed preoperatively.

RESULTS

One hundred four patients were included in the study. The rate of early readmission within 3 months after surgery was 12.5% and the rate of postoperative complications was 40.4%. In multivariate analysis, dependence in the activities of daily living (ADL ≤ 5) was the only factor associated with unplanned readmission (aOR = 9.9, 95% CI 1.9-50.8), and living alone was the only factor associated with postoperative complications (aOR = 3.2, 95% CI 1.2-8.8).

CONCLUSIONS

We found that the ADL score was associated with the risk of unplanned readmission in older patients undergoing planned arthroplasty, and that living alone was associated with postoperative complications. A preoperative mini-CGA appears essential to limit postoperative morbidity.

The Diverse Implementation of Geriatrics-Orthopedics Comanagement Programs in the United States

BACKGROUND

Many health systems are establishing geriatrics-orthopedics (Geri-Ortho) comanagement programs; however, there is paucity of published information on existing programs' variations in clinical operations, structure, and reported implementation challenges and perceived successes.

OBJECTIVE

Our objective was to obtain detailed information about the variety of existing Geri-Ortho comanagement programs in the United States.

DESIGN/PARTICPANTS

We conducted a cross-sectional survey of 44 existing Geri-Ortho comanagement programs, with 23 (52%) of programs responding.

MEASUREMENT

Quantitative questions were used to assess operational, staffing, and financial structures; and qualitative questions were used to identify reported challenges and perceived successes of implementation.

RESULTS

Programs self-identified as urban (n = 23), academic (n = 20), or nonprofit (n = 22) and as having a level I trauma center (n = 17). Most programs (n = 18) were funded fully by the institution. Fourteen programs used geriatricians, and nine used medicine/hospitalists as the supporting clinical service, whereas approximately half (n = 11) used these services in a true comanagement model. Six universal themes were identified as necessary for program implementation. The most commonly described successes perceived by all respondents were improvements in clinical outcomes and better interdisciplinary relationships. Reported challenges included difficulty in interdisciplinary geriatrics education, difficulty in adherence to protocols, and lack of funding for staffing.

CONCLUSIONS

There are diverse types of Geri-Ortho comanagement programs in the United States, although universal elements exist. Many had similar challenges in implementation, and further studies are needed to determine which implementation elements are critical to clinical and financial outcomes. J Am Geriatr Soc 68:1714-1719, 2020.

Management of hip fracture in the older people: rationale and design of the Italian consensus on the orthogeriatric co-management

BACKGROUND

Hip fracture (HF) is a burdening health problem in older people. The orthogeriatric approach has been shown to favour functional recovery and reduce mortality, but its implementation in clinical practice cannot rely upon shared management protocols and greatly varies among different healthcare systems. Here, we present the rationale and design of the Italian consensus document on the management of HF in older people.

METHODS

A panel of multidisciplinary experts from ten Italian scientific societies involved in the care of HF and including geriatricians, orthopaedics, anaesthesiologists, physiatrists and general practitioners, will join to establish the content validity of a list of statements. A Delphi consensus methodology will be applied to obtain the opinions of the panel and to provide the final recommendations.

OBJECTIVES

The document will include indications on the following relevant topics: (1) optimal care path of older subjects with HF; (2) management of comorbidities and pre-operative alteration of physiological parameters; (3) management of selected categories of patients at expected increased risk of adverse outcomes; (4) continuity of care out of hospital; (5) screening and correction of risk factors for HF in older subjects; (6) information and divulgation of shared management strategies. The objective of the consensus will be to inform clinicians, patients, researchers, and health policy makers about the best management strategies for HF in older people and their inherent limitations, thus facilitating communication between stakeholders and promoting the most cost/effective models of care.

Risk factors and mortality of patients undergoing hip fracture surgery: a one-year follow-up study

Hip fracture (HF) remains a main issue in the elderly patient. About 1.6 million patients a year worldwide are victims of a HF. Their incidence is expected to rise with the aging of the world’s population. Identifying risk factors is mandatory in order to reduce mortality and morbidity. The aim of the study was to identify risk factors of 1-year mortality after HF surgery. We performed an observational, prospective, single-center study at Amiens University Hospital (Amiens, France). After ethical approval, we consecutively included all patients with a HF who underwent surgery between June 2016 and June 2017. Perioperative data were collected from medical charts and by interviews. Mortality rate at 12 months was recorded. Univariate analysis was performed and mortality risk factors were investigated using a Cox model. 309 patients were analyzed during this follow-up. Mortality at 1 year was 23.9%. Time to surgery over 48 hours involved 181 patients (58.6%) while 128 patients (41.4%) had surgery within the 48 hours following the hospital admission. Independent factors associated with 1-year mortality were: age (HR at 1.059 (95%CI [1.005–1.116], p = 0,032), Lee score ≥ 3 (HR at 1,52 (95% CI [1,052–2,198], p = 0.026) and time to surgery over 48 hours (HR of 1.057 (95% CI [1.007–1.108], p = 0.024). Age, delayed surgical (over 48 hours) management and medical history are important risk factors of 1-year mortality in this French cohort