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Armstrong E, Rogers K, Li CS, Jagnoor J, Moroz P, Oguzie GC, Hailu S, Miclau T, de la Huerta F, Martinez-Ruiz JDJ, Bidolegui F, Zhou J, Ma X, Wu B, Sancheti P, Quang LN, Baigi V, Haddadi M, Tian M, Sprague S, Devereaux PJ, Bhandari M, Ivers R. Time from injury to hip-fracture surgery in low-income and middle-income regions: a secondary analysis of data from the International Orthopaedic Multicentre Study in Fracture Care (INORMUS). THE LANCET. HEALTHY LONGEVITY 2024; 5:e552-e562. [PMID: 39025101 DOI: 10.1016/s2666-7568(24)00062-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Globally, fall-related injuries are a substantial problem, and 80% of fatal falls occur in low-income and middle-income countries. We aimed to measure time from injury to hip-fracture surgery in people aged 50 years or older living in low-income and middle-income regions, as well as to measure the proportion of patients with surgical stabilisation of their hip fracture within 72 h of admission to hospital and to identify risk factors associated with surgical delay. METHODS For this secondary analysis, we analysed data collected from Africa, Latin America, China, India, and Asia (excluding China and India) for the International Orthopaedic Multicentre Study in Fracture Care (INORMUS) between March 29, 2014, and June 15, 2022. Patients from INORMUS were included in this analysis if they were aged 50 years or older and had an isolated, primary hip fracture sustained from a ground-level fall. Staff at participating hospitals identified patients with musculoskeletal injury and referred them for assessment of eligibility. We report time from injury to surgery as three distinct time periods: time from injury to hospital admission, time from admission to surgery, and a total time from injury to surgery. Date and time of injury were self-reported by patients at the time of study recruitment. If time to hospital admission after injury exceeded 24 h, patients reported the primary reason for delayed admission. Reasons for surgery, no surgery, and surgical delay were reported by the treating team. For patients undergoing surgery, multivariable regression analyses were used to identify risk factors for surgical delay. FINDINGS 4486 adults aged 50 years or older with an isolated, primary hip fracture were enrolled in INORMUS from 55 hospitals in 24 countries. Countries were grouped into five regions: Africa (418 [9·3%] of 4486), Latin America (558 [12·4%]), China (1680 [37·4%]), India (1059 [23·6%]) and Asia (excluding China and India; 771 [17·2%]). Of 4486 patients, 3805 (84·8%) received surgery. The rate of surgery was similar in all regions except in Africa, where only 193 (46·3%) of 418 patients had surgery. Overall, 2791 (62·2%) of 4486 patients were admitted to hospital within 24 h of injury. However, 1019 (22·7%) of 4486 patients had delayed hospital admission of 72 h or more from injury. The two most common reasons for delayed admission of more than 24 h were transfer from another hospital (522 [36·2%] of 1441) and delayed care-seeking because patients thought the injury would heal on its own (480 [33·3%]). Once admitted to hospital, 1451 (38·1%) of 3805 patients who received surgery did so within 72 h (median 4·0 days [IQR 1·7-6·0]). Regional variation was seen in the proportion of patients receiving surgery within 72 h of hospital admission (92 [17·9%] of 514 in Latin America, 53 [27·5%] of 193 in Africa, 454 [30·9%] of 1471 in China, 318 [44·4%] of 716 in Asia [excluding China and India], and 534 [58·6%] of 911 in India). Of all 3805 patients who received operative treatment, 2353 (61·8%) waited 72 h or more from hospital admission. From time of injury, the proportion of patients who were surgically stabilised within 72 h was 889 (23·4%) of 3805 (50 [9·7%] of 517 in Latin America, 31 [16·1%] of 193 in Africa, 277 [18·8%] of 1471 in China, 189 [26·4%] of 716 in Asia [excluding China and India], and 342 [37·5%] of 911 in India). INTERPRETATION Access to surgery within 72 h of hospital admission was poor, with factors that affected time to surgery varying by region. Data are necessary to understand existing pathways of hip-fracture care to inform the local development of quality-improvement initiatives. FUNDING The National Health and Medical Research Council of Australia, the Canadian Institutes of Health Research, McMaster Surgical Associates, Hamilton Health Sciences, and the US National Institutes of Health.
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Affiliation(s)
- Elizabeth Armstrong
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Kris Rogers
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Chuan Silvia Li
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jagnoor Jagnoor
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Paul Moroz
- Department of Surgery, John A Burns School of Medicine, University of Hawaii, Honolulu, HI, USA
| | | | - Samuel Hailu
- College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | - Theodore Miclau
- Department of Orthopaedic Surgery, School of Medicine, University of California, San Francisco, CA, USA
| | - Fernando de la Huerta
- Faculty of Medicine, Division of Orthopaedic Surgery, University Hospital, Mexican Institute of Social Security, Mexico City, Mexico
| | | | - Fernando Bidolegui
- Orthopaedic and Trauma Surgery Department, Sirio-Libanes Hospital, Buenos Aires, Argentina; Departamento de Ortopedia y Traumatologia, Sanatorio Otamendi, Buenos Aires, Argentina
| | - Junlin Zhou
- Department of Orthopaedics, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinlong Ma
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Bo Wu
- Department of Joint Surgery, Orthopedic Hospital of Shenyang, Shenyang, China
| | - Parag Sancheti
- Department of Spine, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India
| | - La Ngoc Quang
- Department of Epidemiology, Hanoi University of Public Health, Hanoi, Viet Nam
| | - Vali Baigi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mashyaneh Haddadi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Injury Prevention and Safety Promotion Department, Disaster and Emergency Management Center, Ministry of Health and Medical Education, Tehran, Iran
| | - Maoyi Tian
- School of Public Health, Harbin Medical University, Harbin, China
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Mohit Bhandari
- Centre for Evidence-Based Orthopaedics, McMaster University, Hamilton, ON, Canada
| | - Rebecca Ivers
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
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Lee SW, Holt J, Joung KM, Ayutyanont N. Characteristics and Factors Associated With Nonoperative Management and Hospital Outcomes After Hip Fractures Among Community-Dwelling Older Adults: Retrospective Analysis. J Appl Gerontol 2024:7334648241265204. [PMID: 39030728 DOI: 10.1177/07334648241265204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Nonoperative treatment is used at varying rates among older adults with hip fractures despite the high mortality. This retrospective analysis of 7803 patients 65 and older admitted with hip fractures is to estimate the odds of nonoperative treatment and in-hospital mortality after hip fractures among community-dwelling older adults. 13.6% underwent nonoperative treatment. Compared to the group with operative treatment, the nonoperative group had a higher in-hospital mortality rate (6.51% vs. 1.32%, p < .0001). Male sex, nondisplaced fracture, and comorbidities of acute myocardial infarction, congestive heart failure, cerebrovascular disorder, dementia, and liver disease were associated with an increased likelihood of nonoperative treatment. Nonoperative treatment, advanced age, use of osteoporosis pharmacotherapy, multiple medical comorbidities, and hospital-acquired complications were associated with increased in-hospital mortality. Specific characteristics were associated with nonoperative management and in-hospital mortality among older adults with hip fractures. Additional research is necessary to improve the care of this vulnerable population.
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Affiliation(s)
- Se Won Lee
- Sunrise Health GME Consortium, MountainView Hospital, Las Vegas, NV, USA
| | - Jonathan Holt
- Sunrise Health GME Consortium, MountainView Hospital, Las Vegas, NV, USA
| | - Keong M Joung
- Department of Physical Medicine and Rehabilitation, VA Southern Nevada Healthcare system, Las Vegas, NV, USA
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Nakamura K, Sasaki T, Yokoyama M, Kitagawa T, Akashi Y, Shimizu M. Factors Associated With Ambulation Status and Survival One Year After Conservative Management of Hip Fracture. Cureus 2024; 16:e64253. [PMID: 39131017 PMCID: PMC11314690 DOI: 10.7759/cureus.64253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
PURPOSE Few studies have investigated the factors associated with ambulation and survival over one year. Therefore, this study aimed to examine the factors that influence ambulation and survival rates in elderly patients who have undergone conservative management for hip fractures. MATERIALS AND METHODS This retrospective study included 74 ambulatory individuals aged 65 years or older prior to their injuries. One-year mortality and ambulatory status were assessed. Statistical comparisons of background and medical characteristics between groups of independent and non-independent walkers, as well as between survivors and mortalities, were performed using the Pearson chi-squared, Fisher exact, and Mann-Whitney U tests. RESULTS The numbers of older patients able to walk independently, those not able to walk independently, and those with mortality at one-year post-injury after conservative management of hip fractures were 13 (18.3%), 35 (49.3%), and 23 (32.4%), respectively. Independent walkers one year after conservative treatment for hip fracture were younger (p=0.04) and less likely to have cognitive impairment (p=0.04) than non-independent walkers. The proportion of individuals with cognitive impairment was found to be lower among survivors than among mortalities (p=0.0098). CONCLUSION Cognitive decline may contribute to difficulties in walking independently and mortality at one year post-injury in this population.
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Affiliation(s)
- Keisuke Nakamura
- Department of Physical Therapy, Shinshu University, Matsumoto, JPN
| | - Tomohiro Sasaki
- Department of Rehabilitation, Matsumoto City Hospital, Matsumoto, JPN
| | - Marin Yokoyama
- Department of Rehabilitation, Matsumoto City Hospital, Matsumoto, JPN
| | - Takashi Kitagawa
- Department of Physical Therapy, Shinshu University, Matsumoto, JPN
| | - Yuto Akashi
- Department of Physical Therapy, Shinshu University, Matsumoto, JPN
| | - Masayuki Shimizu
- Department of Orthopedics, Matsumoto City Hospital, Matusmoto, JPN
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Schoenfeld AJ, Xiang L, Adler RR, Schoenfeld AL, Kang JD, Weissman JS. Clinical Outcomes Following Operative and Nonoperative Management of Odontoid Fractures Among Elderly Individuals with Dementia. J Bone Joint Surg Am 2024:00004623-990000000-01137. [PMID: 38896721 DOI: 10.2106/jbjs.23.00835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND The incidence of odontoid fractures among the elderly population has been increasing in recent years. Elderly individuals with dementia may be at increased risk for inferior outcomes following such fractures. Although surgical intervention has been maintained to optimize survival and recovery, it is unclear if this benefit extends to patients with dementia. We hypothesized that patients with dementia who were treated operatively for odontoid fractures would experience improved survival and lower rates of hospice admission but higher rates of delirium and of intensive interventions. METHODS We used Medicare claims data (2017 to 2018) to identify community-dwelling individuals with dementia who sustained type-II odontoid fractures. We considered treatment strategy (operative or nonoperative) as the primary predictor and survival as the primary outcome. The secondary outcomes consisted of post-treatment delirium, hospice admission, post-treatment intensive intervention, and post-discharge admission to a nursing home or a skilled nursing facility. In all models, we controlled for age, biological sex, race, Elixhauser Comorbidity Index, Frailty Index, admission source, treating hospital, and dual eligibility. Adjusted analyses for survival were conducted using Cox proportional hazards regression. Adjusted analyses for secondary outcomes were performed using generalized estimating equations. To address confounding by indication, we performed confirmatory analyses using inverse probability of treatment weighting. RESULTS In this study, we included 1,030 patients. The median age of the cohort was 86.5 years (interquartile range, 80.9 to 90.8 years), 60.7% of the patients were female, and 90% of the patients were White. A surgical procedure was performed in 19.8% of the cohort. Following an adjusted analysis, patients treated surgically had a 28% lower hazard of mortality (hazard ratio, 0.72 [95% confidence interval (CI), 0.53 to 0.98]), but higher odds of delirium (odds ratio, 1.64 [95% CI, 1.10 to 2.44]). These findings were preserved in the inverse probability weighted analysis. CONCLUSIONS We found that, among individuals with dementia who sustain a type-II odontoid fracture, surgical intervention may confer a survival benefit. A surgical procedure may be an appropriate treatment strategy for individuals with dementia whose life-care goals include life prolongation and maximizing quality of life in the short term following an injury. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lingwei Xiang
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel R Adler
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - James D Kang
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joel S Weissman
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Loggers SAI, Van Balen R, Willems HC, Gosens T, Polinder S, Ponsen KJ, Van de Ree CLP, Steens J, Verhofstad MHJ, Zuurmond RG, Joosse P, Van Lieshout EMM. The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis. Am J Hosp Palliat Care 2024; 41:583-591. [PMID: 37403839 PMCID: PMC11032625 DOI: 10.1177/10499091231180556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD 'good to almost perfect'. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.
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Affiliation(s)
- Sverre A. I. Loggers
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, the Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Romke Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Hanna C. Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC Location AMC, Amsterdam, the Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kornelis J. Ponsen
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | | | - Jeroen Steens
- Department of Orthopaedic Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Pieter Joosse
- Department of Surgery, Northwest Clinics Alkmaar, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Baumann AN, Talaski GM, Uhler MA, Anastasio AT, Walley KC, Pean CA, Tampi RR, Farivar M. The Utilization of Preoperative Steroids Safely Decreases the Risk of Postoperative Delirium in Geriatric Patients After Hip Fracture Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Orthop Trauma 2024; 38:e182-e190. [PMID: 38300234 DOI: 10.1097/bot.0000000000002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVES Postoperative delirium is an acute neurocognitive complication that can have adverse effects on outcomes of geriatric patients after undergoing hip fracture surgery. The objective of this study was to examine the efficacy of preoperative steroids in preventing postoperative delirium after hip fracture surgery. METHODS DATA SOURCES A systematic review and meta-analysis was performed using PubMed, SPORTDiscus, CINAHL, MEDLINE, and Web of Science from database inception until September 28, 2023. STUDY SELECTION Inclusion criteria were randomized controlled trials of patients who underwent surgical intervention for hip fracture, were examined for postoperative delirium, and used preoperative steroids. DATA EXTRACTION Data included the risk of postoperative delirium, postoperative all-cause infection, and postoperative hyperglycemia. Articles were graded via the Cochrane Collaboration's tool. DATA SYNTHESIS Statistical analysis included a random-effects binary model with relative risk, 95% confidence intervals along with a defined "number needed to treat" threshold (number needed to treat). RESULTS Four randomized controlled trials were included from 128 articles initially retrieved. Patients (n = 416; average age: 82.2 ± 2.2 years) underwent surgical intervention for hip fracture after receiving either preoperative steroids (n = 209) or control interventions (n = 207). There was a statistically significant decrease in the incidence of postoperative delirium among patients who received preoperative steroids (12.9%; 27 cases) as compared with patients who received control interventions (26.7%; 55 cases) after hip fracture surgery ( P < 0.001; RR: 0.84). The absolute risk difference was 13.8%, and the number needed to treat was 7.2 patients. There was no statistically significant difference in the risk of postoperative all-cause infection among patients who received preoperative steroids as compared with patients who received normal saline as placebo after hip fracture surgery ( P = 0.850; RR: 0.96). CONCLUSIONS The utilization of preoperative steroids seems to decrease the risk of postoperative delirium after hip fracture surgery in elderly adults. Furthermore, this decreased risk of postoperative delirium was not associated with a significant increase in postoperative infection, indicating possible safety of preoperative steroid administration. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anthony N Baumann
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | | | - Mathias A Uhler
- College of Biological Sciences, University of Akron, Akron, OH
| | | | - Kempland C Walley
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI
| | | | - Rajesh R Tampi
- Department of Psychiatry, Creighton University, Omaha, NE
| | - Michel Farivar
- Department of Psychiatry, Cleveland Clinic Akron General, Akron, OH
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Adler RR, Xiang L, Shah SK, Clark CJ, Cooper Z, Mitchell SL, Kim DH, Hsu J, Sepucha K, Chunga RE, Lipsitz SR, Weissman JS, Schoenfeld AJ. Hip Fracture Treatment and Outcomes Among Community-Dwelling People Living With Dementia. JAMA Netw Open 2024; 7:e2413878. [PMID: 38814642 PMCID: PMC11140536 DOI: 10.1001/jamanetworkopen.2024.13878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 05/31/2024] Open
Abstract
Importance The decision for surgical vs nonsurgical treatment for hip fracture can be complicated among community-dwelling people living with dementia. Objective To compare outcomes of community-dwelling people living with dementia treated surgically and nonsurgically for hip fracture. Design, Setting, and Participants This retrospective cross-sectional study undertook a population-based analysis of national Medicare fee-for-service data. Participants included community-dwelling Medicare beneficiaries with dementia and an inpatient claim for hip fracture from January 1, 2017, to June 30, 2018. Analyses were conducted from November 10, 2022, to October 17, 2023. Exposure Surgical vs nonsurgical treatment for hip fracture. Main Outcomes and Measures The primary outcome was mortality within 30, 90, and 180 days. Secondary outcomes consisted of selected post-acute care services. Results Of 56 209 patients identified with hip fracture (73.0% women; mean [SD] age, 86.4 [7.0] years), 33 142 (59.0%) were treated surgically and 23 067 (41.0%) were treated nonsurgically. Among patients treated surgically, 73.3% had a fracture of the femoral head and neck and 40.2% had moderate to severe dementia (MSD). Among patients with MSD and femoral head and neck fracture, 180-day mortality was 31.8% (surgical treatment) vs 45.7% (nonsurgical treatment). For patients with MSD treated surgically vs nonsurgically, the unadjusted odds ratio (OR) of 180-day mortality was 0.56 (95% CI, 0.49-0.62; P < .001) and the adjusted OR was 0.59 (95% CI, 0.53-0.66; P < .001). Among patients with mild dementia and femoral head and neck fracture, 180-day mortality was 26.5% (surgical treatment) vs 34.9% (nonsurgical treatment). For patients with mild dementia who were treated surgically vs nonsurgically for femoral head and neck fracture, the unadjusted OR of 180-day mortality was 0.67 (95% CI, 0.60-0.76; P < .001) and the adjusted OR was 0.71 (95% CI, 0.63-0.79; P < .001). For patients with femoral head and neck fracture, there was no difference in admission to a nursing home within 180 days when treated surgically vs nonsurgically. Conclusions and Relevance In this cohort study of community-dwelling patients with dementia and fracture of the femoral head and neck, patients with MSD and mild dementia treated surgically experienced lower odds of death compared with patients treated nonsurgically. Although avoiding nursing home admission is important to persons living with dementia, being treated surgically for hip fracture did not necessarily confer a benefit in that regard. These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach.
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Affiliation(s)
- Rachel R. Adler
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Samir K. Shah
- Division of Vascular Surgery, University of Florida, Gainesville
| | - Clancy J. Clark
- Division of Surgical Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Susan L. Mitchell
- Hebrew SeniorLife, Marcus Institute for Aging Research, Boston, Massachusetts
| | - Dae Hyun Kim
- Hebrew SeniorLife, Marcus Institute for Aging Research, Boston, Massachusetts
| | - John Hsu
- Mongan Institute Health Policy Center, Mass General Research Institute, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Karen Sepucha
- Health Decision Sciences Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Richard E. Chunga
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stuart R. Lipsitz
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew J. Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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8
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Yang Y, Drake SA, Wang J, Shen GC, Miao H, Morgan RO, Du XL, Lairson DR. Comparing survival rates and mortality in operative versus nonoperative treatment for femoral neck fractures among Alzheimer's disease patients: A retrospective cohort study. Aging Med (Milton) 2024; 7:52-59. [PMID: 38571673 PMCID: PMC10985770 DOI: 10.1002/agm2.12279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/28/2023] [Accepted: 12/05/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Addressing femoral neck fractures resulting from ground-level falls in older adults with Alzheimer's disease (AD) involves a personalized treatment plan. There is considerable ongoing debate concerning the relative advantages and disadvantages of surgical treatment (internal fixation or arthroplasty) vs nonoperative treatment for femoral neck fractures in older persons with AD. Methods This retrospective cohort study compared the mortality, hazard ratio, and survival rate between operative and nonoperative treatments, controlling for patients' demographic information and baseline health status. The study population consisted of Optum beneficiaries diagnosed with AD who experienced an initial femoral neck fracture claim between January 1, 2012, and December 31, 2017. Kaplan-Meier survival curves were applied to compare the treatment groups' post-fracture survival rates and mortality. Cox regression was used to examine the survival period by controlling the covariates. Results Out of the 4157 patients with AD with femoral neck fractures, 59.8% were women (n = 2487). The median age was 81 years. The 1-year survival rate for nonoperative treatment (70.19%) was lower than that for internal fixation (75.27%) and arthroplasty treatment (82.32%). Compared with the nonoperative group, arthroplasty surgical treatment had significant lower hazard risk of death (arthroplasty hazard ratio: 0.850, 95% CI: 0.728-0.991, P < 0.05). Discussion The findings suggest that the operative treatment group experiences higher survival rates and lower mortality rates than the nonoperative group. This paper provides insights into treatment outcomes of older adults with AD receiving medical care for femoral neck fractures.
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Affiliation(s)
- Yijiong Yang
- College of NursingFlorida State UniversityTallahasseeFloridaUSA
| | - Stacy A. Drake
- School of NursingBowling Green State UniversityBowling GreenOhioUSA
| | - Jing Wang
- College of NursingFlorida State UniversityTallahasseeFloridaUSA
| | - Gordon C. Shen
- Department of Management, Policy and Community Health, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Hongyu Miao
- College of NursingFlorida State UniversityTallahasseeFloridaUSA
- Department of StatisticsFlorida State UniversityTallahasseeFloridaUSA
| | - Robert O. Morgan
- Department of Management, Policy and Community Health, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - David R. Lairson
- Department of Management, Policy and Community Health, School of Public HealthThe University of Texas Health Science Center at HoustonHoustonTexasUSA
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Li X, Gong X, He L, Wu X. Current surgical status of hip fracture among elderly in China. Injury 2024; 55:111083. [PMID: 37858446 DOI: 10.1016/j.injury.2023.111083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 09/03/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE Hip fracture patients are recommended to undergo surgery within 24-36 h. The present study aimed to analyze the current status of hip fracture surgery among the elderly in China. METHODS The baseline information, such as the patient's age, gender, place of residence, place of treatment, fracture type, admission, and operation time, of hip fracture patients >65-years-old were retrieved from the hospital quality monitoring system (HQMS) database from 2013 to 2017 and analyzed. RESULTS A total of 304,279 patients >65-years-old with hip fractures were included in this study. The average length of hospital stay was 15 days, and the average waiting time for surgery after admission was 96 h. The average surgery rate of elderly hip fractures in China was 59.6 %, of which the lowest was recorded in the Northwest China (46.4 %). CONCLUSIONS The major issues in diagnosing and treating elderly patients with hip fractures in China are the long waiting time for surgery and the low surgery rate.
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Affiliation(s)
- Xinping Li
- Department of Geriatrics, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Xiaofeng Gong
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China.
| | - Liang He
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Xinbao Wu
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
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10
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Bellova P, Linne M, Postler AE, Günther KP, Stiehler M, Goronzy J. Girdlestone resection arthroplasty for femoral neck fractures has poorer outcomes than hemiarthroplasty in frail patients with increased risk for arthroplasty-related complications: a retrospective case study of 21 patients. Acta Orthop 2024; 95:61-66. [PMID: 38288960 PMCID: PMC10826842 DOI: 10.2340/17453674.2024.34901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 11/23/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND AND PURPOSE Hemiarthroplasty (HA) is the usual treatment for displaced femoral neck fractures (FNF) in elderly patients. Patients may be unsuitable for HA due to secondary conditions such as systemic infections or severe neurological conditions, which is why Girdlestone resection arthroplasty (GRA) may be an option. We aimed to determine (1) patient survival in matched patient groups treated with either GRA or HA and (2) functional outcomes. PATIENTS AND METHODS 21 patients treated with GRA for FNF in a German university hospital were retrospectively reviewed (2015-2019). After matching for age and comorbidities, a control group of 42 HA patients was established. Patient survival was determined by a Kaplan-Meier analysis. The mean follow-up (FU) was 1.5 (0-4.4) years. Function at FU was documented using the modified Harris Hip Score (mHHS) and the National Hip Fracture Database (NHFD) mobility score. RESULTS The 1-month-mortality was 19% in the GRA group and 12% in the HA group; the 1-year mortality was 71% and 49%, respectively (P = 0.01). The mHHS at FU was lower in the GRA group than in the HA group (22 [range 0-50] vs. 46 [11-80]). 82% of patients in the GRA group were bedridden post-surgery as opposed to 19% in the HA group. CONCLUSION Patients with HA after FNF had higher survival and better functional outcomes when compared with GRA in matched patient groups. Considering this, GRA for FNF should be selected restrictively.
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Affiliation(s)
- Petri Bellova
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany.
| | - Marcus Linne
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Anne Elisabeth Postler
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Klaus-Peter Günther
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Maik Stiehler
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
| | - Jens Goronzy
- Department of Orthopaedics, Trauma and Plastic Surgery, University Clinic Garl Gustav Carus, Technical University (TU) Dresden, Germany
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11
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Zabawa L, Choubey AS, Drake B, Mayo J, Mejia A. Dementia and Hip Fractures: A Comprehensive Review of Management Approaches. JBJS Rev 2023; 11:01874474-202312000-00002. [PMID: 38079493 DOI: 10.2106/jbjs.rvw.23.00157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.
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Affiliation(s)
- Luke Zabawa
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Apurva S Choubey
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Brett Drake
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
| | - Joel Mayo
- University of Illinois College of Medicine, Chicago, Illinois
| | - Alfonso Mejia
- Department of Orthopaedics, University of Illinois at Chicago, Chicago, Illinois
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12
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Burrack N, Hatfield LA, Bakx P, Banerjee A, Chen YC, Fu C, Godoy Junior C, Gordon M, Heine R, Huang N, Ko DT, Lix LM, Novack V, Pasea L, Qiu F, Stukel TA, Uyl-de Groot C, Ravi B, Al-Azazi S, Weinreb G, Cram P, Landon BE. Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study. J Am Geriatr Soc 2023; 71:3780-3791. [PMID: 37565425 PMCID: PMC10840946 DOI: 10.1111/jgs.18530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. METHODS We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery. RESULTS The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). CONCLUSIONS We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.
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Affiliation(s)
- Nitzan Burrack
- Clinical Research Center, Soroka University Medical Center, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Pieter Bakx
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals, London, UK
| | - Yu-Chin Chen
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Christina Fu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Godoy Junior
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Michal Gordon
- Clinical Research Center, Soroka University Medical Center, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Renaud Heine
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, Canada
- ICES, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Laura Pasea
- Institute of Health Informatics, University College London, London, UK
| | | | - Therese A Stukel
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Carin Uyl-de Groot
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Saeed Al-Azazi
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Cram
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, UTMB, Galveston, Texas, USA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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13
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Xiang L, Singh M, McNicoll L, Moppett IK. Clinician perspectives on nonoperative management of hip fractures during COVID-19. Bone Jt Open 2023; 4:766-775. [PMID: 37827525 PMCID: PMC10569888 DOI: 10.1302/2633-1462.410.bjo-2023-0069.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
Aims To identify factors influencing clinicians' decisions to undertake a nonoperative hip fracture management approach among older people, and to determine whether there is global heterogeneity regarding these factors between clinicians from high-income countries (HIC) and low- and middle-income countries (LMIC). Methods A SurveyMonkey questionnaire was electronically distributed to clinicians around the world through the Fragility Fracture Network (FFN)'s Perioperative Special Interest Group and clinicians' personal networks between 24 May and 25 July 2021. Analyses were performed using Excel and STATA v16.0. Between-group differences were determined using independent-samples t-tests and chi-squared tests. Results A total of 406 respondents from 51 countries answered the questionnaire, of whom 225 came from HIC and 180 from LMIC. Clinicians from HIC reported a greater median and mean estimated proportion of admitted patients with hip fracture undergoing surgery (median 96% (interquartile range (IQR) 95% to 99%); mean 94% (SD 8%)) than those from LMIC (median 85% (IQR 75% to 95%); mean 81% (SD 16%); p < 0.001). Global heterogeneity seems to exist regarding factors such as anticipated life expectancy, insufficient resources, ability to pay, treatment costs, and perception of risk in hip fracture management decision-making. Conclusion This study represents the first international sampling of clinician perspectives regarding nonoperative hip fracture management. Several factors seemed to influence the clinician decision-making process. Further research is needed to inform the development of best practice guidelines to improve decision-making and the quality of hip fracture care among older people.
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Affiliation(s)
- Lucille Xiang
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Mriganka Singh
- Division of Geriatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Lynn McNicoll
- Division of Geriatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Iain K. Moppett
- Anaesthesia and Critical Care, Injury, Recovery & Inflammation Sciences, The University of Nottingham, Queen’s Medical Centre, Nottingham, UK
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14
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Tzeng HM, Downer B, Li CY, Raji M, Haas A, Kuo YF. Association Between Cognitive Impairment and Repeat Fractures in Medicare Beneficiaries Recently Hospitalized for Hip Fracture. J Gerontol A Biol Sci Med Sci 2023; 78:1677-1682. [PMID: 36810779 PMCID: PMC10460551 DOI: 10.1093/gerona/glad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Repeat fractures contribute substantially to fracture incidents in older adults. We examined the association between cognitive impairment and re-fractures during the first 90 days after older adults with hip fractures were discharged home from a skilled nursing facility rehabilitation short stay. METHODS Multilevel binary logistic regression was used to analyze 100% of U.S. national postacute-care fee-for-service Medicare beneficiaries who had a hospital admission for hip fracture from January 1, 2018, to July 31, 2018; were admitted for a skilled nursing facility stay within 30 days of hospital discharge; and were discharged to the community after a short stay. Our primary outcome was rehospitalization for any re-fractures within 90 days of skilled nursing facility discharge. Cognitive status assessed at skilled nursing facility admission or before discharge was classified as either intact or having mild or moderate/severe impairment. RESULTS In 29 558 beneficiaries with hip fracture, odds of any re-fracture were higher in those with minor (odds ratio: 1.48; 95% confidence interval: 1.19-1.85; p < .01) and moderate/major cognitive impairment (odds ratio: 1.42; 95% confidence interval: 1.07-1.89; p = .0149) than in those classified as intact. CONCLUSIONS Beneficiaries with cognitive impairment were more likely than their counterparts with no cognitive impairment to experience re-fractures. Community-dwelling older adults with minor cognitive impairment may experience a higher likelihood of experiencing a repeat fracture leading to rehospitalization.
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Affiliation(s)
- Huey-Ming Tzeng
- School of Nursing, University of Texas Medical Branch, Galveston, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, USA
| | - Brian Downer
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, USA
- School of Health Professions, University of Texas Medical Branch, Galveston, USA
| | - Chih-Ying Li
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, USA
- School of Health Professions, University of Texas Medical Branch, Galveston, USA
| | - Mukaila A Raji
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, USA
- Department of Internal Medicine, John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA
| | - Allen Haas
- Office of Biostatics, University of Texas Medical Branch, Galveston, USA
| | - Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, USA
- Office of Biostatics, University of Texas Medical Branch, Galveston, USA
- Department of Biostatistics & Data Science, School of Public and Population Health, University of Texas Medical Branch, Galveston, USA
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15
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Huang JW, Yang YF, Gao XS, Xu ZH. A single preoperative low-dose dexamethasone may reduce the incidence and severity of postoperative delirium in the geriatric intertrochanteric fracture patients with internal fixation surgery: an exploratory analysis of a randomized, placebo-controlled trial. J Orthop Surg Res 2023; 18:441. [PMID: 37337260 DOI: 10.1186/s13018-023-03930-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery. METHODS Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score. RESULTS There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71-0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups. CONCLUSIONS A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery. TRIAL REGISTRATION ChiCTR2200055281.
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Affiliation(s)
- Jian-Wen Huang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
| | - Yun-Fa Yang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China.
| | - Xiao-Sheng Gao
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
| | - Zhong-He Xu
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, The Second Affiliated Hospital, School of Medicine, South China University of Technology, 1 Panfu Road, Guangzhou, 510180, Guangdong, China
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16
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Wang MT, Chang CC, Liu CC, Fan Chiang YH, Shih YRV, Lee YW. General versus Neuraxial Anesthesia on Clinical Outcomes in Patients Receiving Hip Fracture Surgery: An Analysis of the ACS NSQIP Database. J Clin Med 2023; 12:jcm12113827. [PMID: 37298022 DOI: 10.3390/jcm12113827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
Whether the use of neuraxial anesthesia or general anesthesia leads to more favorable postoperative outcomes in patients receiving hip fracture surgery remains unclear. We used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Data Files between 2016 and 2020 to investigate the association of neuraxial anesthesia and general anesthesia with morbidity and mortality after hip fracture surgery. Inverse probability of treatment weighting (IPTW) was used to balance the baseline characteristics, and multivariable Cox regression models were used to estimate the hazard ratio (HR) with a 95% confidence interval (CI) for postoperative morbidity and mortality among the different anesthesia groups. A total of 45,874 patients were included in this study. Postoperative adverse events occurred in 1087 of 9864 patients (11.0%) who received neuraxial anesthesia and in 4635 of 36,010 patients (12.9%) who received general anesthesia. After adjustment for IPTW, the multivariable Cox regressions revealed that general anesthesia was associated with increased risks of postoperative morbidity (adjusted HR, 1.19; 95% CI, 1.14-1.24) and mortality (adjusted HR, 1.09; 95% CI, 1.03-1.16). The results of the present study suggest that, compared with general anesthesia, neuraxial anesthesia is associated with lower risks of postoperative adverse events in patients undergoing hip fracture surgery.
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Affiliation(s)
- Ming-Tse Wang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, Taitung MacKay Memorial Hospital, Taitung 95054, Taiwan
| | - Chuen-Chau Chang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chih-Chung Liu
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yu-Hsuan Fan Chiang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Yu-Ru Vernon Shih
- Department of Orthopaedic Surgery, Duke University, Durham, NC 27708, USA
| | - Yuan-Wen Lee
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
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17
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Loggers SAI, Geraerds AJLM, Joosse P, Willems HC, Gosens T, Van Balen R, Van de Ree CLP, Ponsen KJ, Steens J, Zuurmond RG, Verhofstad MHJ, Polinder S, Van Lieshout EMM. Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study. Osteoporos Int 2023; 34:515-525. [PMID: 36609506 PMCID: PMC9908658 DOI: 10.1007/s00198-022-06638-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023]
Abstract
UNLABELLED Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM. PURPOSE The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture. METHODS This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective. RESULTS Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs. CONCLUSION OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL. TRIAL REGISTRATION Netherlands Trial Register (NTR7245; date 10-06-2018).
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Affiliation(s)
- S A I Loggers
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM, Alkmaar, the Netherlands
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - A J L M Geraerds
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - P Joosse
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, P.O. Box 1074, 1940 EB, Beverwijk, the Netherlands
| | - H C Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC Location AMC, P.O. Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - T Gosens
- Department of Orthopedic Surgery, Elisabeth-TweeSteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, the Netherlands
| | - R Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - C L P Van de Ree
- Department Trauma TopCare, Elisabeth-TweeSteden Ziekenhuis, P.O. Box 90151, 5000 LC, Tilburg, the Netherlands
| | - K J Ponsen
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM, Alkmaar, the Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, P.O. Box 1074, 1940 EB, Beverwijk, the Netherlands
| | - J Steens
- Department of Orthopedic Surgery, Dijklander Ziekenhuis, P.O. Box 600, 1620 AR, Hoorn, the Netherlands
| | - R G Zuurmond
- Department of Orthopedic Surgery, Isala, P.O. Box 10400, 8000 GK, Zwolle, the Netherlands
| | - M H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - S Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands.
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Backhouse T, Fox C, Hammond SP, Poland F, McDermott-Thompson V, Penhale B, Cross JL. Implementing an intervention to enhance care delivery and consistency for people with hip fracture and cognitive impairment in acute hospital wards: a mixed methods process evaluation of a randomised controlled feasibility trial (PERFECTED). BMJ Open 2023; 13:e064482. [PMID: 36737086 PMCID: PMC9900060 DOI: 10.1136/bmjopen-2022-064482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To determine how, and under what circumstances, the PERFECT-ER intervention was implemented in five acute hospital wards and impacted on staff practices and perceptions. DESIGN Mixed methods process evaluation (undertaken between 2016 and 2018). SETTING Five acute hospital wards across three different UK regions. PARTICIPANTS Patients (n=3) admitted to acute wards with hip fracture and cognitive impairment, their relatives (n=29) and hospital staff (n=63). INTERVENTIONS PERFECT-ER, a multicomponent intervention designed to enhance the recovery of patients with hip fracture and cognitive impairment was implemented for 18 months. PERFECT-ER was implemented at ward level ensuring that multiple new and existing practices were undertaken consistently, on the assumption that collectively, small individual advances would improve care delivery for patients. PRIMARY AND SECONDARY OUTCOME MEASURES Implementation of the PERFECT-ER intervention examined through regular intervention scores, service improvement staff reports and action plans, and semi-structured interviews and focus groups. RESULTS The process evaluation identified points of implementation vulnerability and strength. All wards implemented some elements of PERFECT-ER. Implementation was fragile when ward pressures were high and when ward staff perceived the relative priority of intervention practices to be low. Adaptations to the implementation process may have reduced whole-ward staff engagement with implementation. However, strategical enlistment of senior ward influencers (such as ward managers, orthogeriatricians) combined with service improvement lead in-ward peer pressure tactics facilitated implementation processes. CONCLUSIONS Our study suggests that implementation was expediated when senior staff were on board as opinion leaders and formally appointed internal implementation leaders exerted their power. Within hierarchical settings such as acute wards, key individuals appeared to influence implementation through endorsement and sometimes enforcement. This indicates that whole-ward interventions may not always require cognitive engagement from all ward staff to implement changes. Future ward-level implementation studies could consider how best to engage staff and most importantly, which staff to best target. TRIAL REGISTRATION NUMBER ISRCTN99336264.
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Affiliation(s)
- Tamara Backhouse
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Simon P Hammond
- School of Education & Lifelong Learning, Univeristy of East Anglia, Norwich, UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, UK
| | | | - Bridget Penhale
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Jane L Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
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Xue TM, Pan W, Tsumura H, Wei S, Lee C, McConnell ES. Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis. J Am Med Dir Assoc 2023; 24:235-241.e2. [PMID: 36525987 DOI: 10.1016/j.jamda.2022.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/03/2022] [Accepted: 11/05/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Older adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring. DESIGN Retrospective observational cohort study using EHRs. SETTING AND PARTICIPANTS A cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia. METHODS Logistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling. RESULTS Dementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19-3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20-2.38], 1-year mortality (HR = 1.78, 95% CI 1.33-2.38), 180-day readmission (HR = 1.62, 95% CI 1.39-1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21-1.58). CONCLUSIONS AND IMPLICATIONS Dementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.
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Affiliation(s)
- Tingzhong Michelle Xue
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Wei Pan
- Duke University School of Nursing, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | | | - Sijia Wei
- Center for Education in Health Sciences, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Chiyoung Lee
- University of Washington Bothell, School of Nursing and Health Studies, Bothell, WA, USA
| | - Eleanor S McConnell
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
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Hailu S, Tesfaye S, Alemayehu G. Osteoporosis-related appendicular fractures in Tikur Anbessa Specialized Hospital, Ethiopia: a prospective observational study. Arch Osteoporos 2023; 18:21. [PMID: 36652030 DOI: 10.1007/s11657-023-01214-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023]
Abstract
We examined the frequency of osteoporotic fractures among patients presenting to Tikur Anbessa Specialized Hospital. Osteoporotic fractures accounted for 10.4% of all fractures and 31.8% of those 40 years and older. In addition, hip fractures accounted for 60%. Therefore, devising strategies for preventing, treating, and rehabilitating osteoporotic fractures is critical. PURPOSE Examine the frequency of osteoporotic fractures among patients presenting to Tikur Anbessa Specialized Hospital. METHODS This is an observational study of prospectively collected data between January 2018 and December 2021. Patients were categorized as having osteoporotic fracture if they were 40 years or older, sustained a low-energy injury, and had characteristic fracture patterns to the hip, proximal humerus, distal radius, tibia (in females only), clavicle, and scapula. A descriptive analysis was carried out to assess patient demographics. Risk factors were then evaluated using a binary logistic regression model. RESULTS A total of 4712 orthopedic injury patients presented to the emergency department with 4422 fracture cases. Of these, 461 fulfilled the diagnostic criteria for osteoporotic fractures. The overall rate of osteoporotic fractures was 10.4% of all patients with fractures and 31.8% of those 40 years or older. Overall, 63.3% were female. One in four females and 5% of males with musculoskeletal trauma had an osteoporotic fracture. Osteoporotic hip fractures made up 59.9% of osteoporotic fractures and 5.9% of all fractures, followed by distal radius (23%), tibia in females (8.2%), and proximal humerus (7.4%). Pelvis (2.6%), clavicle (0.9%), and scapula (0.2%) fractures were found to be rare. Among all patients with fractures following low-energy injuries, when patients were aged 50 years and older, there was a higher risk that the trauma resulted in an osteoporotic fracture. This figure was highest among those aged 80 years and older (odds ratio (OR), 11.88; 95% CI, 7.01-20.11). CONCLUSIONS Further studies need to be done to show the prevalence of osteoporosis and osteoporotic fractures in Ethiopia and examine risk factors. Devising strategies for preventing, treating, and rehabilitating osteoporotic fractures is critical.
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Affiliation(s)
- Samuel Hailu
- Tikur Anbessa Specialized Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Samuel Tesfaye
- Tikur Anbessa Specialized Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gabriel Alemayehu
- Tikur Anbessa Specialized Hospital, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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21
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Predictors of Hospice Discharge After Surgical Fixation of Hip Fractures. J Am Acad Orthop Surg 2023; 31:e35-e43. [PMID: 36394941 DOI: 10.5435/jaaos-d-21-01015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 08/05/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Each year, over 300,000 people older than 65 years are hospitalized for hip fractures. Given the notable morbidity and mortality faced by elderly patients in the postinjury period, recommendations have been put forth for integrating palliative and, when needed, hospice care to improve patients' quality of life. Our objective was to (1) understand the proportion of patients discharged to hospice after hip fracture surgery and their 30-day mortality rates and (2) identify the independent predictors of discharge to hospice. METHODS We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program for all hip fracture surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and nonhospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and nonhospice patients were compared using chi-squared analysis or the Fisher exact test for categorical variables and Student t -tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. RESULTS Overall, 31,531 surgically treated hip fractures were identified, of which only 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison with 5.6% of patients not discharged to hospice ( P < 0.001). Disseminated cancer, dependent functional status, >10% weight loss over 6 months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality after hip fracture surgery. CONCLUSIONS Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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22
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Grosman S, Scott IA. Quality of observational studies of clinical interventions: a meta-epidemiological review. BMC Med Res Methodol 2022; 22:313. [PMID: 36476329 PMCID: PMC9727931 DOI: 10.1186/s12874-022-01797-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 10/06/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This meta-epidemiological study aimed to assess methodological quality of a sample of contemporary non-randomised clinical studies of clinical interventions. METHODS This was a cross-sectional study of observational studies published between January 1, 2012 and December 31, 2018. Studies were identified in PubMed using search terms 'association', 'observational,' 'non-randomised' 'comparative effectiveness' within titles or abstracts. Each study was appraised against 35 quality criteria by two authors independently, with each criterion rated fully, partially or not satisfied. These quality criteria were grouped into 6 categories: justification for observational design (n = 2); minimisation of bias in study design and data collection (n = 11); use of appropriate methods to create comparable groups (n = 6); appropriate adjustment of observed effects (n = 5); validation of observed effects (n = 9); and authors interpretations (n = 2). RESULTS Of 50 unique studies, 49 (98%) were published in two US general medical journals. No study fully satisfied all applicable criteria; the mean (+/-SD) proportion of applicable criteria fully satisfied across all studies was 72% (+/- 10%). The categories of quality criteria demonstrating the lowest proportions of fully satisfied criteria were measures used to adjust observed effects (criteria 20, 23, 24) and validate observed effects (criteria 25, 27, 33). Criteria associated with ≤50% of full satisfaction across studies, where applicable, comprised: imputation methods to account for missing data (50%); justification for not performing an RCT (42%); interaction analyses in identifying independent prognostic factors potentially influencing intervention effects (42%); use of statistical correction to minimise type 1 error in multiple outcome analyses (33%); clinically significant effect sizes (30%); residual bias analyses for unmeasured or unknown confounders (14%); and falsification tests for residual confounding (8%). The proportions of fully satisfied criteria did not change over time. CONCLUSIONS Recently published observational studies fail to fully satisfy more than one in four quality criteria. Criteria that were not or only partially satisfied were identified which serve as remediable targets for researchers and journal editors.
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Affiliation(s)
- Sergei Grosman
- grid.412744.00000 0004 0380 2017Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, Queensland 4102 Australia ,grid.413210.50000 0004 4669 2727Department of Medicine, Cairns Hospital, 165 The Esplanade, Cairns, Queensland 4870 Australia
| | - Ian A. Scott
- grid.412744.00000 0004 0380 2017Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, 199 Ipswich Road, Brisbane, Queensland 4102 Australia
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Kim H, Juarez CA, Meath THA, Quiñones AR, Teno JM. Association of Medicare bundled payment model with joint replacement care for people with dementia. J Am Geriatr Soc 2022; 70:2571-2581. [PMID: 35635471 PMCID: PMC9489623 DOI: 10.1111/jgs.17836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 04/17/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND We examined whether the Comprehensive Care for Joint Replacement (CJR) model was associated with changes in the receipt of joint replacement among people with Alzheimer's disease and related dementias (ADRD) as well as spending, health service use, and postsurgical outcomes among people with ADRD who underwent a joint replacement surgery. METHODS Retrospective cohort study using 2013-2017 Medicare claims and Minimum Data Set. We used a difference-in-differences analysis to compare people with ADRD residing in CJR-participating treatment areas versus nonparticipating control areas on the receipt of joint replacement, episode spending during the index hospitalization and subsequent 90-day post-discharge period, discharges to an institutional post-acute care setting, and readmissions within 90 days of hospital discharge. RESULTS Our sample included 3,361,950 Medicare enrollees with ADRD (2,156,995 women [64%]; mean [SD] age, 83 [8.0] years; 2,646,405 white [78%], 344,478 black [10%], 224,010 Hispanic [7%]). The receipt of replacement among people with ADRD changed similarly between CJR-participating treatment and control areas after CJR model was implemented, suggesting no association of CJR model with the receipt of replacement. Among people with ADRD who received joint replacement, the CJR model was associated with a $1029 decrease in spending per episode (95% confidence interval [CI] -$1577, -$481, p < 0.001), a 1.62 percentage point decrease in discharges to an institutional post-acute care setting (95% CI -3.17, -0.07, p = 0.04), but no changes in 90-day readmission (95% CI -2.68, 0.00, p = 0.051). CONCLUSIONS Despite concerns that the CJR model could hinder people with ADRD from receiving joint replacement, the receipt of joint replacement did not change among people with ADRD under CJR. The CJR model was associated with decreased spending for people with ADRD who received joint replacements, driven by reduced discharges to an institutional post-acute care setting, without any changes in 90-day readmission.
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Affiliation(s)
- Hyunjee Kim
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Cesar A Juarez
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas H A Meath
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joan M Teno
- Department of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Spronk I, Loggers SAI, Joosse P, Willems HC, Van Balen R, Gosens T, Ponsen KJ, Steens J, van de Ree CLP(M, Zuurmond RG, Verhofstad MHJ, Van Lieshout EMM, Polinder S. Shared decision-making for the treatment of proximal femoral fractures in frail institutionalised older patients: healthcare providers' perceived barriers and facilitators. Age Ageing 2022; 51:6653485. [PMID: 35930725 PMCID: PMC9355456 DOI: 10.1093/ageing/afac174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Proximal femoral fractures are common in frail institutionalised older patients. No convincing evidence exists regarding the optimal treatment strategy for those with a limited pre-fracture life expectancy, underpinning the importance of shared decision-making (SDM). This study investigated healthcare providers' barriers to and facilitators of the implementation of SDM. METHODS Dutch healthcare providers completed an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators. If ≥20% of participants responded with 'totally disagree/disagree', items were considered barriers and, if ≥80% responded with 'agree/totally agree', items were considered facilitators. RESULTS A total of 271 healthcare providers participated. Five barriers and 23 facilitators were identified. Barriers included the time required to both prepare for and hold SDM conversations, in addition to the reflective period required to allow patients/relatives to make their final decision, and the number of parties required to ensure optimal SDM. Facilitators were related to patients' values, wishes and satisfaction, the importance of SDM for patients/relatives and the fact that SDM is not considered complex by healthcare providers, is considered to be part of routine care and is believed to be associated with positive patient outcomes. CONCLUSION Awareness of identified facilitators and barriers is an important step in expanding the use of SDM. Implementation strategies should be aimed at managing time constraints. High-quality evidence on outcomes of non-operative and operative management can enhance implementation of SDM to address current concerns around the outcomes.
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Affiliation(s)
- Inge Spronk
- Address correspondence to: Inge Spronk. Tel: +31 107038460.
| | - Sverre A I Loggers
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM Alkmaar, The Netherlands
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM Alkmaar, The Netherlands
| | - Hanna C Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC location AMC, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Romke Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - Kornelis J Ponsen
- Department of Surgery, Northwest Clinics Alkmaar, P.O Box 501, 1800 AM Alkmaar, The Netherlands
- Department of Surgery, Rode Kruis Ziekenhuis, PO Box 1074, 1940 EB Beverwijk, The Netherlands
| | - Jeroen Steens
- Department of Orthopaedic Surgery, Dijklander Ziekenhuis, PO Box 600, 1620 AR Hoorn, The Netherlands
| | - C L P (Marc) van de Ree
- Department Trauma TopCare, Elisabeth-TweeSteden Ziekenhuis, PO Box 90151, 5000 LC Tilburg, The Netherlands
| | - Rutger G Zuurmond
- Department of Orthopaedic Surgery, Isala, PO Box 10400, 8000 GK Zwolle, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Suzanne Polinder
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Loggers SAI, Nijdam TMP, Folbert EC, Hegeman JHH, Van der Velde D, Verhofstad MHJ, Van Lieshout EMM, Joosse P. Prognosis and institutionalization of frail community-dwelling older patients following a proximal femoral fracture: a multicenter retrospective cohort study. Osteoporos Int 2022; 33:1465-1475. [PMID: 35396653 PMCID: PMC9187528 DOI: 10.1007/s00198-022-06394-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/30/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients. INTRODUCTION Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture. METHODS A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m2 and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery. RESULTS A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P25-P75 80-89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation. CONCLUSION Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.
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Affiliation(s)
- S A I Loggers
- Department of Surgery, Northwest Clinics Alkmaar, P.O. Box 501, 1800 AM, Alkmaar, The Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - T M P Nijdam
- Department of Surgery, St. Antonius Ziekenhuis, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - E C Folbert
- Department of Trauma Surgery, Ziekenhuisgroep Twente, P.O. Box 7600, 7600 SZ, Almelo, The Netherlands
| | - J H H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, P.O. Box 7600, 7600 SZ, Almelo, The Netherlands
| | - D Van der Velde
- Department of Surgery, St. Antonius Ziekenhuis, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - E M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - P Joosse
- Department of Surgery, Northwest Clinics Alkmaar, P.O. Box 501, 1800 AM, Alkmaar, The Netherlands
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Loggers SAI, Willems HC, Van Balen R, Gosens T, Polinder S, Ponsen KJ, Van de Ree CLP, Steens J, Verhofstad MHJ, Zuurmond RG, Van Lieshout EMM, Joosse P. Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study. JAMA Surg 2022; 157:424-434. [PMID: 35234817 PMCID: PMC8892372 DOI: 10.1001/jamasurg.2022.0089] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population. Objective To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy. Design, Setting, and Participants This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2). Exposures Shared decision-making (SDM) followed by nonoperative or operative fracture management. Main Outcomes and Measures The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire). Results Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8. Conclusions and Relevance Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.
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Affiliation(s)
- Sverre A. I. Loggers
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Hanna C. Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam University Medical Center location AMC, Amsterdam, the Netherlands
| | - Romke Van Balen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Taco Gosens
- Department of Orthopaedic Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kornelis J. Ponsen
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands,Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | | | - Jeroen Steens
- Department of Orthopaedic Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
| | - Michael H. J. Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Esther M. M. Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands,Department of Surgery, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
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Incidence and risk factors of preoperative deep venous thrombosis following hip fracture: a retrospective analysis of 293 consecutive patients. Eur J Trauma Emerg Surg 2022; 48:3141-3147. [DOI: 10.1007/s00068-021-01861-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/12/2021] [Indexed: 12/27/2022]
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Allahabadi S, Roostan M, Roddy E, Ward DT, Rogers S, Kim C. Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use. Geriatr Orthop Surg Rehabil 2022; 13:21514593221116331. [PMID: 37101932 PMCID: PMC10123378 DOI: 10.1177/21514593221116331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures. Materials and Methods This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups. Results Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging. Discussion Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ. Conclusion Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.
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Affiliation(s)
- Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Mohammad Roostan
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Erika Roddy
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Derek T. Ward
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Stephanie Rogers
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Candace Kim
- Department of Internal Medicine, Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
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Wijnen HH, Schmitz PP, Es-Safraouy H, Roovers LA, Taekema DG, Van Susante JLC. Nonoperative management of hip fractures in very frail elderly patients may lead to a predictable short survival as part of advance care planning. Acta Orthop 2021; 92:728-732. [PMID: 34319206 PMCID: PMC8635672 DOI: 10.1080/17453674.2021.1959155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Surgical treatment is still the mainstay of care even in very frail elderly hip fracture patients. However, one may argue whether surgery is in the best interest of all patients. We elucidated mortality rates of nonoperative management (NOM) of a hip fracture after shared decision-making in a cohort of very frail elderly patients.Patients and methods - Orthogeriatric patients (age > 70 years) admitted with a hip fracture between 2011 and 2019 were included. In the presence of fragility features the motivation for surgery or NOM was supported by advance care planning (ACP) and shared decision-making through geriatric assessment. Mortality rates after NOM were assessed and also presented for the remaining surgical group for reference.Results - In 1,279 out of 3,467 patients, geriatric assessment was indicated and subsequently 1,188 (93%) had surgery versus 91 (7%) NOM. The motivation for NOM was based on patient and family preferences in only 20% of patients, medical grounds in 54%, and a combination of both in 26%. The 30-day and 1-year mortality in the frail NOM group was 87% and 99% respectively, whereas this was 7% and 28% in the surgery group. No statistical comparison between groups was performed due to profound bias by indication.Interpretation - This study provides further insight into the predictable and high short-term mortality after NOM in carefully selected very frail elderly hip fracture patients. This information may help to consider NOM as an alternative treatment option to surgery when no significant gain from surgery is anticipated.
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Affiliation(s)
- Hugo H Wijnen
- Department of Clinical Geriatrics, Rijnstate, Arnhem
| | - Peter P Schmitz
- Department of Orthopedics, Rijnstate, Arnhem;;,Correspondence:
| | | | - Lian A Roovers
- Clinical Research Department, Rijnstate, Arnhem, the Netherlands
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Affiliation(s)
- Cecilia Rogmark
- Department of Orthopaedics, Lund University, Skane University Hospital, Malmö, Sweden;,E-mail:
| | - Niels Lynøe
- Department of Learning, Informatics, Management and Ethics, Stockholm Centre for Healthcare Ethics, Karolinska Institutet, Stockholm, Sweden
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Femoral neck fractures: Key points to consider for fixation or replacement a narrative review of recent literature. Injury 2021; 54 Suppl 1:S70-S77. [PMID: 34615597 DOI: 10.1016/j.injury.2021.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Femoral neck fractures (FNF) are frequent injuries and not rarely complicated by non-union, implant failure, and avascular necrosis. Some of these fractures represent a dilemma for trauma surgeons. Which fracture should be fixed? Which replaced with a prosthesis? How? The aim of this narrative review is to investigate the literature in order to provide the most updated and evidence-based knowledge about FNF' treatment. MATERIALS AND METHODS A literature research has been performed to find the essential key points to consider when dealing with FNF and their treatment. The most representative papers and the new meta-analysis were matched with authors' experience to give a concise but comprehensive view of the problem. Timing, age, comorbidities, vascularization of the femoral head, displacement, instability, comminution of the fracture, bone quality, and surgeon experience seem to be the major topics to consider in the decision making. We then focus on the optimal fixation or replacement as suggested by the literature. RESULTS Age is the main independent factor to consider. Timing seems essential in the elderly population to reduce mortality and important in the younger patients to reduce complications. Vascular supply should be always considered. Displacement, instability, and comminution of the fracture are negative prognostic factors for fixation as well as, theoretically, bone quality. In the elderly hip replacement is mostly indicated. A stable and solid fixation is mandatory to allow early mobilization. Sliding Hip Screws (SHS) seem preferable to cannulated screws for displaced/unstable (Pauwels II-III, posterior comminution) and basicervical fracture patterns or in smokers. There is a tendency toward Total Hip Arthroplasty (THA) also in the elderly if the patient is an indipendent ambulator without severe comorbidities. Dual mobility cups are gaining popularity in THA for FNF. CONCLUSIONS FNF are frequent injuries and represent, in some cases, a dilemma for the trauma surgeon. Age, timing, comorbidities, bone quality, femoral head vascularization, fracture displacement, intrinsic instability, and comminution as surgeon experience should be carefully evaluated before surgery. A case-to-case analysis of the patient-related factors helps the surgeon to make the right choice and reduce the well-known complications.
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Whitehead PB, Gamaluddin S, DeWitt S, Stewart C, Kim KY. Caring for Patients With Dementia at End of Life. Am J Hosp Palliat Care 2021; 39:716-724. [PMID: 34519251 DOI: 10.1177/10499091211046247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Care of the dementia patient continues to be challenging. It is a terminal condition that many times goes undiagnosed leading to improper evidence-based interventions. Healthcare professionals (HCPs) should initiate goals of care conversations early with patients and their families in order to align treatment preferences. Early integration of palliative medicine is an important intervention that can lead to better manage symptoms and lessen the strain on loved ones. Additionally, early enrollment into hospice should be encouraged with loved ones to promote quality of life as defined by the patient.
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Affiliation(s)
- Phyllis B Whitehead
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | | | - Sarah DeWitt
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Christi Stewart
- Carilion Roanoke Memorial Hospital Palliative Care Service, Roanoke, VA, USA.,Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Center for Healthy Aging, Roanoke, VA, USA
| | - Kye Y Kim
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Carilion Center for Healthy Aging, Roanoke, VA, USA
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Ríos-Germán PP, Gutierrez-Misis A, Queipo R, Ojeda-Thies C, Sáez-López P, Alarcón T, Puime AO, Gómez-Campelo P, Navarro-Castellanos L, González-Montalvo JI. Differences in the baseline characteristics, management and outcomes of patients with hip fractures depending on their pre-fracture place of residence: the Spanish National Hip Fracture Registry (RNFC) cohort. Eur Geriatr Med 2021; 12:1021-1029. [PMID: 33970467 DOI: 10.1007/s41999-021-00503-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE One in four hip fracture patients comes from an aged care facility. This study aimed to compare the characteristics of these subjects with their community-dwelling counterparts at baseline, during hospitalization and 1-month post-fracture. METHODS We analyzed data from a cohort of older adults admitted with hip fractures to 75 Spanish hospitals, collected prospectively in the Spanish National Hip Fracture Registry between 2016 and 2018. We classified participants according to pre-fracture residence: community dwellers vs. aged care facilities residents. We collected demographic records at baseline, along with variables relating to in-hospital evolution and discharge to geriatric rehabilitation units. Patients or relatives were interviewed at 1-month follow-up. RESULTS Out of 18,262 patients, 4,422 (24.2%) lived in aged care facilities. Aged care facilities residents were older (median age: 89 vs. 86 years), less mobile (inability to walk independently: 20.8% vs. 9.4%) and had more cognitive impairment (Pfeiffer's SPMSQ > 3, 75.3% vs. 34.8%). They were more likely to receive conservative treatment (5.4% vs. 2.0%) and less likely to be mobilized early (58.2% vs. 63.0%). At discharge, they received less vitamin D supplements (68.5% vs. 72.4%), less anti-osteoporotic medication (29.3% vs. 44.3%), and were referred to geriatric rehabilitation units less frequently (5.4% vs. 27.5%). One-month post-fracture, 45% of aged care facilities residents compared to 28% of community dwellers experienced a severe gait decline. Aged care facilities residents had a higher one-month mortality (10.6% vs. 6.8%). CONCLUSION Hip fracture patients from aged care facilities are more vulnerable than their community-dwelling peers and are managed differently both during hospitalization and at discharge. Gait decline is disproportionately higher among those admitted from aged care.
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Affiliation(s)
- Peggy P Ríos-Germán
- Department of Geriatric Medicine, Geriatric Service, Hospital Universitario La Paz, Paseo La Castellana 261, 28046, Madrid, Spain. .,La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.
| | - Alicia Gutierrez-Misis
- La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Rocío Queipo
- La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.,European University of Madrid, Madrid, Spain
| | - Cristina Ojeda-Thies
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Pilar Sáez-López
- La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Geriatric Medicine, Hospital Universitario Fundación de Alcorcón, Madrid, Spain
| | - Teresa Alarcón
- Department of Geriatric Medicine, Geriatric Service, Hospital Universitario La Paz, Paseo La Castellana 261, 28046, Madrid, Spain.,La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Angel Otero Puime
- La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Paloma Gómez-Campelo
- La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain
| | | | - Juan Ignacio González-Montalvo
- Department of Geriatric Medicine, Geriatric Service, Hospital Universitario La Paz, Paseo La Castellana 261, 28046, Madrid, Spain.,La Paz University Hospital Institute for Health Research (IdiPAZ), Madrid, Spain.,Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Zhang J, Zhu J, Liu Z, Zhang Y, Jin Y, Wang M, Zhang X, He K, Zhang Y. Predictive factors associated with the clinical outcome of intertrochanteric hip fracture in high-risk elderly patients treated with total hip arthroplasty versus percutaneous external fixation. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:740. [PMID: 34268353 PMCID: PMC8246164 DOI: 10.21037/atm-20-8037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/17/2021] [Indexed: 11/17/2022]
Abstract
Background Little is known regarding the survival and functional recovery of elderly intertrochanteric hip fracture (IHF) patients after total hip arthroplasty (THA) versus percutaneous external fixation (PEF). This study aims to analyze the prognostic factors of THA and PEF in elderly IHF patients. Methods A total of 155 consecutive elderly patients (mean age of 80 years) diagnosed with IHF were retrospectively reviewed from our database between January 1, 2010, and December 31, 2018. The preoperative, intraoperative and postoperative covariates were analyzed by two independent surgical cohorts: THA and PEF. The main outcomes included the hip function score, all-cause mortality within 1 year after surgery, and overall survival. Covariables and their influence on independent outcomes were analyzed using multivariate regression models. Results The median follow-up period was 5.1 years, and 6 patients were lost to follow-up. At the endpoint, 70 of 85 patients treated with THA and 37 of 70 patients treated with PEF survived, exhibiting mean Harris hip scores of 84.4 and 69.0, respectively. The Kaplan-Meier curves and log-rank tests showed no significant difference in overall survival. After adjusting for the covariates, the surgical mode was a unique prognostic factor affecting hip function recovery, and two prognostic factors (leukocyte count and D-dimer) were correlated with 1-year all-cause mortality. Age at admission, fracture classification, D-dimer level and surgical mode were identified as prognostic factors affecting overall survival. After adjusting for the former three covariates, THA reduced the risk of death by 67.20% compared with PEF (HR 0.328, 95% CI, 0.121–0.890). Conclusions Despite the nonsignificant difference in 1-year all-cause mortality, THA demonstrated superior midterm survival and hip function recovery in elderly IHF patients compared with PEF. Predictive factors, including age at admission, fracture classification, D-dimer level and surgical mode, are associated with the overall survival of IHF in high-risk elderly patients.
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Affiliation(s)
- Jun Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jie Zhu
- Department of Neurology, Daping Hospital, Army Medical University, Chongqing, China
| | - Zaiyang Liu
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yumei Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yunfei Jin
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Min Wang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xia Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Kaiqi He
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yuan Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
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Kim SJ, Park HS, Lee DW. Outcome of nonoperative treatment for hip fractures in elderly patients: A systematic review of recent literature. J Orthop Surg (Hong Kong) 2021; 28:2309499020936848. [PMID: 32638635 DOI: 10.1177/2309499020936848] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Many studies have shown that surgical management still leads to the best outcomes in elderly patients with hip fractures, with some studies showing non-inferiority of nonsurgical management as compared to surgery in fragility fractures. Evidence-based guidelines on whether to operate on these patients are lacking. A systematic literature search was conducted regarding outcomes of nonoperatively treated hip fractures in elderly patients with various comorbidities. A structured literature review of multiple databases (PubMed, Web of Science, EMBASE, and Cochrane library) referenced articles from 2000 to 2020. A total of 596 patients from 11 published studies were identified. Mean age was 83.3 years. Overall 328 (69.7%) complications occurred in 470 patients with nonsurgical treatment. Pneumonia and urinary tract infections were the most common complications which occurred in 53 (16.1%) and 46 (14.0%) patients, respectively. Hip fracture patients who were treated nonoperatively had a higher in-hospital (17.1% vs. 4.4%; p < 0.001), 30-day (31.4% vs. 10.2%; p < 0.001), and 1-year (48.5% vs. 19.9%; p < 0.001) mortality compared to a matched group of operatively treated patients (n = 1464). Of the 110 patients whose reported cause of death was nonoperative care, 44 (40%) was due to pneumonia. Patients with nonoperative treatment following hip fracture were associated with substantially higher complication and mortality compared with patients who were treated operatively. Our study will help health-care providers and caregivers to enable more informed decision-making for families and patients confronted with a hip fracture.
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Affiliation(s)
- Seung-Ju Kim
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul, Korea
| | - Hyun-Soo Park
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul, Korea
| | - Dong-Woo Lee
- Department of Orthopaedics, Hanil General Hospital, 308 Uicheon-ro, Dobong-Gu, Seoul, Korea
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Bekeris J, Wilson LA, Bekere D, Liu J, Poeran J, Zubizarreta N, Fiasconaro M, Memtsoudis SG. Trends in Comorbidities and Complications Among Patients Undergoing Hip Fracture Repair. Anesth Analg 2021; 132:475-484. [PMID: 31804405 DOI: 10.1213/ane.0000000000004519] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hip fracture patients represent various perioperative challenges related to their significant comorbidity burden and the high incidence of morbidity and mortality. As population trend data remain rare, we aimed to investigate nationwide trends in the United States in patient demographics and outcomes in patients after hip fracture repair surgery. METHODS After Institutional Review Board (IRB) approval (IRB#2012-050), data covering hip fracture repair surgeries were extracted from the Premier Healthcare Database (2006-2016). Patient demographics, comorbidities, and complications, as well as anesthesia and surgical details, were analyzed over time. Cochran-Armitage trend tests and simple linear regression assessed significance of (linear) trends. RESULTS Among N = 507,274 hip fracture cases, we observed significant increases in the incidence in preexisting comorbid conditions, particularly the proportion of patients with >3 comorbid conditions (33.9% to 43.4%, respectively; P < .0001). The greatest increase for individual comorbidities was seen for sleep apnea, drug abuse, weight loss, and obesity. Regarding complications, increased rates over time were seen for acute renal failure (from 6.9 to 11.1 per 1000 inpatient days; P < .0001), while significant decreasing trends for mortality, pneumonia, hemorrhage/hematoma, and acute myocardial infarction were recorded. In addition, decreasing trends were observed for the use of neuraxial anesthesia either used as sole anesthetic or combined with general anesthesia (7.3% to 3.6% and 6.3% to 3.4%, respectively; P < .0001). Significantly more patients (31.9% vs 41.3%; P < .0001) were operated on in small rather than medium- and large-sized hospitals. CONCLUSIONS From 2006 to 2016, the overall comorbidity burden increased among patients undergoing hip fracture repair surgery. Throughout this same time period, incidence of postoperative complications either remained constant or declined with the only significant increase observed in acute renal failure. Moreover, use of regional anesthesia decreased over time. This more comorbid patient population represents an increasing burden on the health care system; however, existing preventative measures appear to be effective in minimizing complication rates. Although, given the proposed benefits of regional anesthesia, decreased utilization may be of concern.
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Affiliation(s)
- Janis Bekeris
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Lauren A Wilson
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Dace Bekere
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Jashvant Poeran
- Departments of Orthopedics.,Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole Zubizarreta
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Megan Fiasconaro
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York.,Department of Health Policy and Research, Weill Cornell Medical College, New York, New York
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Ma H, Wang H, Long X, Xu Z, Chen X, Li M, He T, Wang W, Liu L, Liu X. Early intravenous tranexamic acid intervention reduces post-traumatic hidden blood loss in elderly patients with intertrochanteric fracture: a randomized controlled trial. J Orthop Surg Res 2021; 16:106. [PMID: 33536047 PMCID: PMC7860029 DOI: 10.1186/s13018-020-02166-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/20/2020] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Elderly patients with intertrochanteric fractures exhibit post-traumatic hidden blood loss (HBL). This study aimed to evaluate the efficacy and safety of reducing post-traumatic HBL via early intravenous (IV) tranexamic acid (TXA) intervention in elderly patients with intertrochanteric fracture. METHODS A prospective randomized controlled study was conducted with 125 patients (age ≥ 65 years, injury time ≤ 6 h) who presented with intertrochanteric fracture from September 2018 and September 2019. Patients in the TXA group (n = 63) received 1 g of IV TXA at admission, whereas those in the normal saline (NS) group (n = 62) received an equal volume of saline. Hemoglobin (Hgb) and hematocrit (Hct) were recorded at post-traumatic admission (PTA) and on post-traumatic days (PTDs) 1-3. HBL was calculated using the Gross formula. Lower extremity venous ultrasound was performed to detect venous thrombosis. RESULTS Hgb on PTDs 2 and 3 was statistically higher in the TXA group than in the NS group. Hct and HBL on PTDs 1-3 were significantly less in the TXA group compared to the NS group. Preoperative transfusion rate was significantly lower in the TXA group compared with the NS group. There was no difference between the two groups with regard to the rates of complications. CONCLUSION Early IV TXA intervention could reduce post-traumatic HBL and pre-operative transfusion rate in elderly patients with intertrochanteric fractures without increasing the risk of venous thrombosis.
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Affiliation(s)
- Huixu Ma
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Hairuo Wang
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Xiaotao Long
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Zexiang Xu
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Xiaohua Chen
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Mingjin Li
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Tao He
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Wei Wang
- Department of Orthopaedics, Chongqing General Hospital, Chongqing, 400021, People's Republic of China
| | - Lei Liu
- Department of Orthopedics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
| | - Xi Liu
- Department of Radiology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, 400022, People's Republic of China.
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Dexter PR, Grout RW, Embi PJ. Transforming primary medical research knowledge into clinical decision. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2021; 2020:358-362. [PMID: 33936408 PMCID: PMC8075430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
While the utility of computerized clinical decision support (CCDS) for multiple select clinical domains has been clearly demonstrated, much less is known about the full breadth of domains to which CCDS approaches could be productively applied. To explore the applicability of CCDS to general medical knowledge, we sampled a total of 500 primary research articles from 4 high-impact medical journals. Employing rule-based templates, we created high-level CCDS rules for 72% (361/500) of primary medical research articles. We subsequently identified data sources needed to implement those rules. Ourfindings suggest that CCDS approaches, perhaps in the form of non-interruptive infobuttons, could be much more broadly applied. In addition, our analytic methods appear to provide a means of prioritizing and quantitating the relative utility of available data sources for purposes of CCDS.
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Affiliation(s)
- Paul R Dexter
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN
| | - Randall W Grout
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN
- Eskenazi Health, Indianapolis, IN
| | - Peter J Embi
- Regenstrief Institute, Inc., Indianapolis, IN
- Indiana University School of Medicine, Indianapolis, IN
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Singh I, Duric D, Motoc A, Edwards C, Anwar A. Relationship of Prevalent Fragility Fracture in Dementia Patients: Three Years Follow up Study. Geriatrics (Basel) 2020; 5:geriatrics5040099. [PMID: 33266236 PMCID: PMC7709649 DOI: 10.3390/geriatrics5040099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: dementia increases the risk of falls by 2–3 times and cognitively impaired patients are three times more likely to have hip fracture following a fall when compared to cognitively intact individuals. However, there is not enough evidence that explores the relationship between dementia and fragility fractures. The aim of this study is to explore the relationships of prevalent fragility fracture in patients with dementia admitted with an acute illness to the hospital. Methods: the existing Health Board records were reviewed retrospectively for all patients admitted diagnosed with dementia in the year 2016. All patients were followed up for a maximum of three years. All of the the dementia patients were divided into three groups: group 1—“no fractures”; group 2—“all fractures”; group 3—“fragility fractures”. Clinical outcomes were analysed for hospital stay, discharge destination (new care home), post-discharge hip fracture data, and mortality. Results: dementia patients with a prevalent fracture were significantly older, 62% were women. A significantly higher proportion of dementia patients with prevalent fractures were care home residents and taking a significantly higher number of medications. The mean Charlson comorbidity index was similar in patients with or without fracture. Dementia patients with a prevalent fracture required a new care home and this is significantly higher when compared to those with no fracture. Mortality at one year and three year was not statistically different in patients with or without prevalent fractures. A significantly higher number (21.5%) of dementia patients with prevalent fragility fracture sustained a new hip fracture when compared to those with no prevalent osteoporotic fracture (2.9%) over the three years follow up (p < 0.0001). Conclusion: dementia patients with a prevalent fragility fracture is associated with a statistically significant higher risk of a new care home placement following acute hospital admission. This sub-group is also at risk of a new hip fracture in the next three years. Whilst clinical judgement remains crucial in the care of frail older people, it is prudent to consider medical management of osteoporosis in dementia if deemed to be beneficial following the comprehensive geriatric assessment.
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Affiliation(s)
- Inderpal Singh
- Department of Geriatric Medicine, Ysbyty Ystrad Fawr, Aneurin Bevan University Health Board, Ystrad Mynach, Wales CF82 7EP, UK; (A.M.); (A.A.)
- Correspondence: ; Tel.: +44-144-380-2234; Fax: +44-144-380-2431
| | - Daniel Duric
- Health Education and Improvement Wales (HEIW), Caerphilly, Wales CF15 7QQ, UK;
| | - Alfe Motoc
- Department of Geriatric Medicine, Ysbyty Ystrad Fawr, Aneurin Bevan University Health Board, Ystrad Mynach, Wales CF82 7EP, UK; (A.M.); (A.A.)
| | - Chris Edwards
- Research and Development Department, Aneurin Bevan University Health Board, Newport, Wales NP20 2UB, UK;
| | - Anser Anwar
- Department of Geriatric Medicine, Ysbyty Ystrad Fawr, Aneurin Bevan University Health Board, Ystrad Mynach, Wales CF82 7EP, UK; (A.M.); (A.A.)
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Loggers SAI, Van Lieshout EMM, Joosse P, Verhofstad MHJ, Willems HC. Prognosis of nonoperative treatment in elderly patients with a hip fracture: A systematic review and meta-analysis. Injury 2020; 51:2407-2413. [PMID: 32907702 DOI: 10.1016/j.injury.2020.08.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/22/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Hip fractures in frail elderly patients are associated with significant mortality and morbidity. Surgery remains the predominant treatment of choice, despite the poor prognosis. Limited research has been done with regards to nonoperative management of frail elderly patients with a hip fracture and therefore the natural course is relatively unknown. This systematic review aimed to provide an overview of the prognosis of nonoperative management in frail elderly patients with a hip fracture in terms of mortality, complications, mobility, and quality of life (QoL). DESIGN A systematic review of the literature was conducted in PubMed, EMBASE, and Cochrane Central. In addition, a meta-analysis was performed. The primary outcome measurement was 30-days mortality. RESULTS A total of 4,318 studies were screened. In total eighteen studies matched the eligibility criteria; with low to moderate quality. Approximately two-thirds of the patients were managed nonoperatively due to medical reasons and one-third due to non-medical reasons. Pooled mortality rates after 30 days, six months and one year were 36%, 46%, and 60%, respectively. 33% of the patients developed in-hospital complications. At six months post trauma, 9.6% of the patients were able to mobilize. Data on quality of life (QoL), functional outcome, pain, comfort during nursing care, and costs were not reported. CONCLUSION Nonoperative management of frail elderly patients with a hip fracture is associated with a poor prognosis. Heterogenous study cohorts and limited outcomes were reported. Current literature shows a lack of evidence of the true prognosis of nonoperative management of frail elderly patient with a hip fracture and a limited life expectancy. Results of this review can be used to aid decision making and improve expectation management.
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Affiliation(s)
- Sverre A I Loggers
- Department of Surgery, Northwest Clinics, P.O Box 501, 1800 AM Alkmaar, Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, Netherlands.
| | - Pieter Joosse
- Department of Surgery, Northwest Clinics, P.O Box 501, 1800 AM Alkmaar, Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, Netherlands
| | - Hanna C Willems
- Geriatrics Section, Department of Internal Medicine, Amsterdam UMC location AMC, P.O. Box 22660, 1100 DD Amsterdam, Netherlands
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Sheehan KJ, Sobolev B, Guy P, Kim JD, Kuramoto L, Beaupre L, Levy AR, Morin SN, Sutherland JM, Harvey EJ. Variation in surgical demand and time to hip fracture repair: a Canadian database study. BMC Health Serv Res 2020; 20:935. [PMID: 33036609 PMCID: PMC7547438 DOI: 10.1186/s12913-020-05791-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals. Methods We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay. Results For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1–6.1), 12.2% (95% CI 10.3–14.2), and 22.0% (95% CI 17.7–26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay. Conclusion Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.
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Affiliation(s)
- Katie J Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason D Kim
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Kuramoto
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lauren Beaupre
- Department of Physical Therapy and Division of Orthopaedic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Jason M Sutherland
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbi, Vancouver, British Columbia, Canada
| | - Edward J Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, Canada
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Schuetze K, Eickhoff A, Rutetzki KS, Richter PH, Gebhard F, Ehrnthaller C. Geriatric patients with dementia show increased mortality and lack of functional recovery after hip fracture treated with hemiprosthesis. Eur J Trauma Emerg Surg 2020; 48:1827-1833. [PMID: 32865595 DOI: 10.1007/s00068-020-01472-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Operative timing, perioperative management and postoperative rehabilitation are rising challenges in orthopedic geriatric trauma. The aim of this study was to determine the outcome of patients with dementia or with a high number of comorbidities treated with hemiprosthesis after hip fracture. Literature regarding patients with high comorbidities is scarce, leaving nothing but endoprosthetic treatment for even the sickest, immobile patients. METHODS A retrospective chart review of 326 patients (mean age 81 ± 9 years; 230 women and 96 men) with hip fractures treated between 2012 and 2017 with a hemiprosthesis was performed. Primary outcome measures were surgical and nonsurgical complication rates, best achievable mobilisation during the hospital stay and mortality. RESULTS Patients with dementia had 20-fold increased risk to be bedridden after surgery and ninefold increased risk of dying (p < 0.005). Furthermore, they needed significantly more revision surgeries because of surgical complications. Patients classified ASA IV and V had significantly lower postoperative mobilization levels with only 10% able to walk with crutches and 53% bedridden. They also had significantly more non-surgical complications while dementia had no effect on non-surgical complication rate. CONCLUSION Patients classified ASA IV and V or suffering dementia show poor outcome after hip fracture treated with hemiprosthesis. Multidisciplinary approaches including surgeons, geriatricians, physiotherapists and psychiatrists are needed to improve the outcome of these patients. Especially in a subgroup of patients, where no mobilization is expected, alternative treatment options may be considered.
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Affiliation(s)
- Konrad Schuetze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Alexander Eickhoff
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Kim-Sarah Rutetzki
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Peter H Richter
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Christian Ehrnthaller
- Department of Trauma Surgery - Campus Innenstadt, Munich University Hospital, Nussbaumstr. 20, 80336, Munich, Germany
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Reyes BJ, Mendelson DA, Mujahid N, Mears SC, Gleason L, Mangione KK, Nana A, Mijares M, Ouslander JG. Postacute Management of Older Adults Suffering an Osteoporotic Hip Fracture: A Consensus Statement From the International Geriatric Fracture Society. Geriatr Orthop Surg Rehabil 2020; 11:2151459320935100. [PMID: 32728485 PMCID: PMC7366407 DOI: 10.1177/2151459320935100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The majority of patients require postacute care (PAC) after a hip fracture. Despite its importance, there is no established consensus regarding the standards of care provided to hip fracture patients in PAC facilities. METHODOLOGY A writing group was created by professionals from the International Geriatric Fracture Society (IGFS) with representation from other organizations. The focus of the statements included in this article is toward PAC providers located in nursing facilities. Contributions were integrated in a single document that underwent several reviews by each author and then underwent a final review by the lead and senior authors. After this process was completed, the document was appraised by reviewers from IGFS. RESULTS/CONCLUSION A total of 15 statements were crafted. These statements summarize the best available evidence and is intended to help PAC facilities managing older adults with hip fractures more efficiently, aiming toward overall better outcomes in the areas of function, quality of life, and with less complications that could interfere with their optimal recovery.
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Affiliation(s)
- Bernardo J. Reyes
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | | | - Nadia Mujahid
- Warren Alpert School of Brown University, Rhode Island, USA
| | | | - Lauren Gleason
- The University of Chicago Medical and Biological Science, IL,
USA
| | | | - Arvind Nana
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
| | - Maria Mijares
- Charles E Schmidt College of Medicine, Florida Atlantic University,
FL, USA
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Sinvani L, Mendelson DA, Sharma A, Nouryan CN, Fishbein JS, Qiu MG, Zeltser R, Makaryus AN, Wolf-Klein GP. Preoperative Noninvasive Cardiac Testing in Older Adults with Hip Fracture: A Multi-Site Study. J Am Geriatr Soc 2020; 68:1690-1697. [PMID: 32526816 DOI: 10.1111/jgs.16555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES For older adults with acute hip fracture, use of preoperative noninvasive cardiac testing may lead to delays in surgery, thereby contributing to worse outcomes. Our study objective was to evaluate the preoperative use of pharmacologic stress testing and transthoracic echocardiogram (TTE) in older adults hospitalized with hip fracture. DESIGN Retrospective chart review. SETTING Seven hospitals (three tertiary, four community) within a large health system. PARTICIPANTS Patients, aged 65 years and older, hospitalized with hip fracture (n = 1,079; mean age = 84.2 years; 75% female; 82% white; 36% married). MEASUREMENTS Data were extracted from electronic medical records. The study evaluated associations between patient factors as well as clinical outcomes (time to surgery [TTS], length of stay [LOS], and in-hospital mortality) and the use of preoperative noninvasive cardiac testing (pharmacologic stress tests or TTE). Descriptive statistics were calculated. Cox regression was performed for both TTS and LOS (evaluated as time-dependent variable); logistic regression was used for in-hospital mortality. RESULTS Although 34.3% (n = 370) had a preoperative TTE, .7% (n = 8) underwent a nuclear stress test and none had a dobutamine stress echocardiogram. Median TTS was 1.1 days (IQR [interquartile range] = .8-1.8 days), median LOS was 5.3 days (IQR = 4.2-7.2 days), and in-hospital mortality was 3% (n = 32). Patients admitted to the medical service had 3.5 times greater odds of undergoing a TTE compared with those on the orthopedic service (P < .001). Community hospitals had almost three times greater odds of preoperative TTE than tertiary centers (P < .001). In multivariable analysis, preoperative TTE was significantly associated with increased TTS (P < .001). No difference in mortality was found between patients with and without a preoperative TTE. CONCLUSION This study highlights the high rate of TTE in preoperative assessment of older adults with acute hip fracture. Given the association between TTE and longer TTS, further studies must clarify the role of preoperative TTE in this population. J Am Geriatr Soc 68:1690-1697, 2020.
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Affiliation(s)
- Liron Sinvani
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Center for Health Innovations Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Daniel A Mendelson
- Department of Medicine, Division of Geriatrics and Aging, University of Rochester, Rochester, New York, USA
| | - Ankita Sharma
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA
| | - Christian N Nouryan
- Division of Hospital Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Center for Health Innovations Research, Feinstein Institutes for Medical Research, Manhasset, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead,, New York, USA
| | - Joanna S Fishbein
- Biostatistics Division, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Michael G Qiu
- Department of Medicine, Northwell Health System, Manhasset, New York, USA
| | - Roman Zeltser
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Cardiology, Nassau University Medical Center, East Meadow, New York, USA
| | - Amgad N Makaryus
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Department of Cardiology, Nassau University Medical Center, East Meadow, New York, USA
| | - Gisele P Wolf-Klein
- Department of Medicine, Northwell Health System, Manhasset, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Hempstead,, New York, USA
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Bukowy EA, Thiel E. Decision Making for Patients with Advanced Dementia and a Hip Fracture #388. J Palliat Med 2020; 23:422-423. [DOI: 10.1089/jpm.2019.0624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Borges FK, Bhandari M, Guerra-Farfan E, Patel A, Sigamani A, Umer M, Tiboni ME, Villar-Casares MDM, Tandon V, Tomas-Hernandez J, Teixidor-Serra J, Avram VRA, Winemaker M, Ramokgopa MT, Szczeklik W, Landoni G, Wang CY, Begum D, Neary JD, Adili A, Sancheti PK, Lawendy AR, Balaguer-Castro M, Ślęczka P, Jenkinson RJ, Nur AN, Wood GCA, Feibel RJ, McMahon SJ, Sigamani A, Popova E, Biccard BM, Moppett IK, Forget P, Landais P, McGillion MH, Vincent J, Balasubramanian K, Harvey V, Garcia-Sanchez Y, Pettit SM, Gauthier LP, Guyatt GH, Conen D, Garg AX, Bangdiwala SI, Belley-Cote EP, Marcucci M, Lamy A, Whitlock R, Le Manach Y, Fergusson DA, Yusuf S, Devereaux PJ, Veevaete L, le Polain de Waroux B, Lavand'homme P, Cornu O, Tribak K, Yombi JC, Touil N, Reul M, Bhutia JT, Clinckaert C, De Clippeleir D, Reul M, Patel A, Tandon V, Gauthier LP, Avram VRA, Winemaker M, de Beer J, Simpson DL, Worster A, Alvarado KA, Gregus KK, Lawrence KH, Leong DP, Joseph PG, Magloire P, Deheshi B, Bisland S, Wood TJ, Tushinski DM, Wilson DAJ, Kearon C, Le Manach Y, Adili A, Tiboni ME, Neary JD, Cowan DD, Khanna V, Zaki A, Farrell JC, MacDonald AM, Conen D, Wong SCW, Karbassi A, Wright DS, Shanthanna H, Coughlin R, Khan M, Wikkerink S, Quraishi FA, Lawendy AR, Kishta W, Schemitsch E, Carey T, Macleod MD, Sanders DW, Vasarhelyi E, Bartley D, Dresser GK, Tieszer C, Jenkinson RJ, Shadowitz S, Lee JS, Choi S, Kreder HJ, Nousiainen M, Kunz MR, Tuazon R, Shrikumar M, Ravi B, Wasserstein D, Stephen DJG, Nam D, Henry PDG, Wood GCA, Mann SM, Jaeger MT, Sivilotti MLA, Smith CA, Frank CC, Grant H, Ploeg L, Yach JD, Harrison MM, Campbell AR, Bicknell RT, Bardana DD, Feibel RJ, McIlquham K, Gallant C, Halman S, Thiruganasambandamoorth V, Ruggiero S, Hadden WJ, Chen BPJ, Coupal SA, McMahon SJ, McLean LM, Shirali HR, Haider SY, Smith CA, Watts E, Santone DJ, Koo K, Yee AJ, Oyenubi AN, Nauth A, Schemitsch EH, Daniels TR, Ward SE, Hall JA, Ahn H, Whelan DB, Atrey A, Khoshbin A, Puskas D, Droll K, Cullinan C, Payendeh J, Lefrancois T, Mozzon L, Marion T, Jacka MJ, Greene J, Menon M, Stiegelmahr R, Dillane D, Irwin M, Beaupre L, Coles CP, Trask K, MacDonald S, Trenholm JAI, Oxner W, Richardson CG, Dehghan N, Sadoughi M, Sharma A, White NJ, Olivieri L, Hunt SB, Turgeon TR, Bohm ER, Tran S, Giilck SM, Hupel T, Guy P, O'Brien PJ, Duncan AW, Crawford GA, Zhou J, Zhao Y, Liu Y, Shan L, Wu A, Muñoz JM, Chaudier P, Douplat M, Fessy MH, Piriou V, Louboutin L, David JS, Friggeri A, Beroud S, Fayet JM, Landais P, Leung FKL, Fang CX, Yee DKH, Sancheti PK, Pradhan CV, Patil AA, Puram CP, Borate MP, Kudrimoti KB, Adhye BA, Dongre HV, John B, Abraham V, Pandey RA, Rajkumar A, George PE, Sigamani A, Stephen M, Chandran N, Ashraf M, Georgekutty AM, Sulthan AS, Adinarayanan S, Sharma D, Barnawal SP, Swaminathan S, Bidkar PU, Mishra SK, Menon J, M N, K VZ, Hiremath SA, NC M, Jawali A, Gnanadurai KR, George CE, Maddipati T, KP MKP, Sharma V, Farooque K, Malhotra R, Mittal S, Sawhney C, Gupta B, Mathur P, Gamangati S, Tripathy V, Menon PH, Dhillon MS, Chouhan DK, Patil S, Narayan R, Lal P, Bilchod PN, Singh SU, Gattu UV, Dashputra RP, Rahate PV, Turiel M, De Blasio G, Accetta R, Perazzo P, Stella D, Bonadies M, Colombo C, Fozzato S, Pino F, Morelli I, Colnaghi E, Salini V, Denaro G, Beretta L, Placella G, Giardina G, Binda M, Marcato A, Guzzetti L, Piccirillo F, Cecconi M, Khor HM, Lai HY, Kumar CS, Chee KH, Loh PS, Tan KM, Singh S, Foo LL, Prakasam K, Chaw SH, Lee ML, Ngim JHL, Boon HW, Chin II, Kleinlugtenbelt YV, Landman EBM, Flikweert ER, Roerdink HW, Brokelman RB, Elskamp-Meijerman HF, Horst MR, Cobben JHMG, Umer M, Begum D, Anjum A, Hashmi PM, Ahmed T, Rashid HU, Khattak MJ, Rashid RH, Lakdawala RH, Noordin S, Juman NM, Khan RI, Riaz MM, Bokhari SS, Almas A, Wahab H, Ali A, Khan HN, Khan EK, Nur AN, Janjua KA, Orakzai SH, Khan AS, Mustafa KJ, Sohail MA, Umar M, Khan SA, Ashraf M, Khan MK, Shiraz M, Furgan A, Ślęczka P, Dąbek P, Kumoń A, Satora W, Ambroży W, Święch M, Rycombel J, Grzelak A, Gucwa J, Machala W, Ramokgopa MT, Firth GB, Karera M, Fourtounas M, Singh V, Biscardi A, Iqbal MN, Campbell RJ, Maluleke ML, Moller C, Nhlapo L, Maqungo S, Flint M, Nejthardt MB, Chetty S, Naidoo R, Guerra-Farfan E, Tomas-Hernandez J, Garcia-Sanchez Y, Garrido Clua M, Molero-Garcia V, Minguell-Monyart J, Teixidor-Serra J, Villar-Casares MDM, Selga Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Aguilar M, Mestre-Torres J, Colomina MJ, Guilabert P, Paños Gozalo ML, Abarca L, Martin N, Usua G, Martinez-Ripol P, Gonzalez Posada MA, Lalueza-Broto P, Sanchez-Raya J, Nuñez Camarena J, Fraguas-Castany A, Balaguer-Castro M, Torner P, Jornet-Gibert M, Serrano-Sanz J, Cámara-Cabrera J, Salomó-Domènech M, Yela-Verdú C, Peig-Font A, Ricol L, Carreras-Castañer A, Martínez-Sañudo L, Herranz S, Feijoo-Massó C, Sianes-Gallén M, Castillón P, Bernaus M, Quintas S, Gómez O, Salvador J, Abarca J, Estrada C, Novellas M, Torra M, Dealbert A, Macho O, Ivanov A, Valldosera E, Arroyo M, Pey B, Yuste A, Mateo L, De Caso J, Anaya R, Higa-Sansone JL, Millan A, Baños V, Herrera-Mateo S, Aguado HJ, Martinez-Municio G, León R, Santiago-Maniega S, Zabalza A, Labrador G, Guerado E, Cruz E, Cano JR, Bogallo JM, Sa-ngasoongsong P, Kulachote N, Sirisreetreerux N, Pengrung N, Chalacheewa T, Arnuntasupakul V, Yingchoncharoen T, Naratreekoon B, Kadry MA, Thayaparan S, Abdlaziz I, Aframian A, Imbuldeniya A, Bentoumi S, Omran S, Vizcaychipi MP, Correia P, Patil S, Haire K, Mayor ASE, Dillingham S, Nicholson L, Elnaggar M, John J, Nanjayan SK, Parker MJ, O'Sullivan S, Marmor MT, Matityahu A, McClellan RT, Comstock C, Ding A, Toogood P, Slobogean G, Joseph K, O'Toole R, Sciadini M, Ryan SP, Clark ME, Cassidy C, Balonov K, Bergese SD, Phieffer LS, Gonzalez Zacarias AA, Marcantonio AJ, Devereaux PJ, Bhandari M, Borges FK, Balasubramanian K, Bangdiwala SI, Harvey V, McGillion MH, Pettit SM, Vincent J, Vincent J, Harvey V, Dragic-Taylor S, Maxwell C, Molnar S, Pettit SM, Wells JR, Forget P, Borges FK, Landais P, Sigamani A, Landoni G, Wang CY, Szczeklik W, Biccard BM, Popova E, Moppett IK, Lamy A, Whitlock R, Ofori SN, Yang SS, Wang MK, Duceppe E, Spence J, Vasquez JP, Marcano-Fernández F, Conen D, Ham H, Tiboni ME, Prada C, Yung TCH, Sanz Pérez I, Neary JD, Bosch MJ, Prystajecky MR, Chowdhury C, Khan JS, Belley-Cote EP, Stella SF, Marcucci M, Heidary B, Tran A, Wawrzycka-Adamczyk K, Chen YCP, Tandon V, González-Osuna A, Patel A, Biedroń G, Wludarczyk A, Lefebvre M, Ernst JA, Staffhorst B, Woodfine JD, Alwafi EM, Mrkobrada M, Parlow S, Roberts R, McAlister F, Sackett D, Wright J. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet 2020; 395:698-708. [PMID: 32050090 DOI: 10.1016/s0140-6736(20)30058-1] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. METHODS HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). FINDINGS Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4-9) in the accelerated-surgery group and 24 h (10-42) in the standard-care group (p<0·0001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0·91 (95% CI 0·72 to 1·14) and absolute risk reduction (ARR) of 1% (-1 to 3; p=0·40). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0·97 (0·83 to 1·13) and an ARR of 1% (-2 to 4; p=0·71). INTERPRETATION Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. FUNDING Canadian Institutes of Health Research.
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Improving peri-operative outcome: Time once more to update protocols. Eur J Anaesthesiol 2020; 37:625-628. [PMID: 32073410 DOI: 10.1097/eja.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nemiroff L, Marshall EG, Jensen JL, Clarke B, Andrew MK. Adherence to “No Transfer to Hospital” Advance Directives Among Nursing Home Residents. J Am Med Dir Assoc 2019; 20:1373-1381. [DOI: 10.1016/j.jamda.2019.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 03/28/2019] [Accepted: 03/29/2019] [Indexed: 10/26/2022]
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Zhang T, Lary CW, Zullo AR, Lee Y, Daiello L, Kiel DP, Berry SD. Post-Hip Fracture Mortality in Nursing Home Residents by Obesity Status. J Am Geriatr Soc 2019; 67:1983-1985. [PMID: 31188465 PMCID: PMC6732026 DOI: 10.1111/jgs.16028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/17/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, United States
| | - Christine W. Lary
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine, United States
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, United States
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, United States
| | - Lori Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, United States
| | - Douglas P. Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, United States
| | - Sarah D. Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, United States
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