European Regional Differences in All-Cause Mortality and Length of Stay for Patients with Hip Fracture

Variation in care and outcome for fragile hip fracture patients: a European multicentre study benchmarking fulfilment of established quality indicators

PURPOSE

Despite the availability of clinical guidelines for hip fracture patients, adherence to these guidelines is challenging, potentially resulting in suboptimal patient care. The goal of this study was (1) to evaluate and benchmark the adherence to recently established quality indicators (QIs), and (2) to study clinical outcomes, in fragile hip fracture patients from different European countries.

METHODS

This observational, cross-sectional multicenter study was performed in 10 hospitals from 9 European countries including data of 298 consecutive patients.

RESULTS

A large variation both within and between hospitals were seen regarding adherence to the individual QIs. QIs with the lowest overall adherence rates were the administration of systemic steroids (5.4%) and tranexamic acid (20.1%). Indicators with the highest adherence rates (above 95%) were pre-operative (99.3%) and post-operative haemoglobin level assessment (100%). The overall median time to surgery was 22.6 h (range 15.7-42.5 h). The median LOS was 9.0 days (range 5.0-19.0 days). The most common complications were delirium (23.2%) and postsurgical constipation (25.2%).

CONCLUSION

The present study shows large variation in the care for fragile patients with hip fractures indicating room for improvement. Therefore, hospitals should invest in benchmarking and knowledge-sharing. Large quality improvement initiatives with longitudinal follow up of both process and outcome indicators should be initiated.

The impact of early mobility on functional recovery after hip fracture surgery

PURPOSE

To examine the effect of early mobility (EM) on functional recovery after hip fracture surgery, and to investigate the potential factors that delay mobility.

METHODS

In this retrospective observational study, 110 hip fracture patients were divided into two groups according to the days between surgery and mobility referred to as the EM and the delayed mobility groups. Demographic data, perioperative data, functional outcomes, and discharge destination were compared statistically between the groups using univariate analysis and logistic regression analysis. As a sensitivity analysis, the factors associated with the timing of physiotherapy were also assessed.

RESULTS

The EM group had significantly better walking ability and Barthel index (p < 0.05), and home discharge rate (p = 0.004). The factors associated with delayed mobility (odds ratio; 95% confidence interval) were delayed postoperative physiotherapy initiation (3.59; 1.76-7.33), days from admission to surgery (1.23; 1.04-1.46), and postoperative CRP (1.14; 1.01-1.29) and hemoglobin level (0.72; 0.54-0.96). Furthermore, patients who received surgery on the day before any holiday were significantly delayed in physiotherapy intervention (p = 0.006).

CONCLUSIONS

This study demonstrated that EM after hip fracture surgery was associated with improving functional recovery and home discharge rate, and early physiotherapy intervention was associated with EM.

Predictive factors for home discharge after femoral fracture surgery: a prospective cohort study

BACKGROUND

Femoral fractures require protracted hospitalization and often preclude return to pre-fracture levels of mobility, function and prior residential status following hospital discharge. Early prediction of rehabilitation and discharge potential in patients with femoral fracture would optimize discharge planning.

AIM

To identify predictive factors of discharge destination during the early phase of femoral fracture rehabilitation.

DESIGN

Prospective cohort design.

SETTING

Acute and postoperative rehabilitation hospital settings.

POPULATION

Data from 109 participants (65 women [59.6%]) admitted for unilateral femoral fracture were included.

METHODS

Sociodemographic information, hip pain severity during gait (Numeric Pain Rating Scale), mobility (Elderly Mobility Scale), activities of daily living (Modified Barthel Index), cognition (Mini-Mental State Examination [MMSE]), exercise self-efficacy (Self-Efficacy for Exercise Scale), amount of physiotherapy received, and caregiver availability were assessed pre- and/or postoperatively. Discharge destination was assessed via telephone interviews 6 weeks after discharge from acute care. Receiver operating characteristic curves were used to determine optimal cut-off scores for all outcomes based on discharge destination. Outcomes demonstrating a significant area under the curve were entered as dichotomous independent variables (i.e., above or below ROC-derived cut-off values) in subsequent logistic regression analyses to determine predictors of discharge destination.

RESULTS

SEE Score ≥53 (odds ratio [OR]=5.975, 95% confidence interval [CI]=1.674-21.333, P=0.006), female sex (OR=3.421, 95% CI=1.187-9.861, P=0.023), ≥8 physiotherapy sessions (OR=4.633, 95% CI=1.559-13.771, P=0.006), MMSE Score ≥17 (OR=3.374, 95% CI=1.047-10.873, P=0.042), and caregiver availability (OR=3.766, 95% CI=1.133-12.520, P=0.030) were identified as significant predictors of home discharge.

CONCLUSIONS

Exercise self-efficacy, female sex, more physiotherapy rehabilitation training, better pre-operative cognitive function, and caregiver availability emerged as important predictors of home discharge following femoral fracture.

CLINICAL REHABILITATION IMPACT

These findings are highly translational and may be useful for informing clinical guidelines and policy decisions regarding rehabilitation potential and discharge pathway selection during early hospitalization following femoral fracture surgery.

Effects of rehabilitation therapy based on exercise prescription on motor function and complications after hip fracture surgery in elderly patients

BACKGROUND

Exercise rehabilitation training is an important measure for improving the prognosis of patients with hip fractures. However, the particular program that works effectively and the efficiency of exercise therapy are still controversial.

OBJECTIVE

To compare the effects of usual postoperative care combined with rehabilitation based on exercise prescription on motor function and complications in elderly patients who underwent surgery for hip fracture.

METHODS

This was an observational study. A total of 71 elderly patients with hip fractures who were treated with hip arthroplasty and internal fixation of the proximal femur with an intramedullary nail at Suzhou Municipal Hospital from October 2020 to December 2021 were included; 11 cases were excluded (eight cases were excluded due to loss of follow-up, two due to deaths from other causes, and one due to other reasons). Finally, 60 patients (18 males and 42 females) were included. Patients were randomly assigned to the control (n = 30) and experimental (n = 30) groups using a random number generator. Patients in the control group received usual postoperative care, whereas those in the experimental group received usual postoperative care combined with rehabilitation training based on the principles of exercise prescription. We recorded the motor function (Harris hip score), daily living ability (Barthel Index), and complications at discharge and 1, 3, and 6 months postoperatively for statistical analysis.

RESULTS

The Harris hip score and Barthel Index score were significantly higher at 1, 3, and 6 months postoperatively than at discharge in both groups (p < 0.05). The Harris hip score and Barthel Index score at discharge and 1, 3, and 6 months postoperatively were significantly higher in the experimental group than in the control group (p < 0.05). The incidence of complications at 6 months postoperatively was significantly lower in the experimental group than in the control group (13% vs. 37%).

CONCLUSIONS

Rehabilitation therapy based on exercise prescription helps improve hip function and the ability to perform activities of daily living and related postoperative complications after hip fracture surgery in elderly patients. The findings of our study will guide decision-making in clinical practice and improve the clinical management of hip fractures in elderly patients postoperatively.

Geographic variation in hip fracture surgery rate, care quality and outcomes: a comparison between national registries in Ireland and Denmark

Ireland and Denmark have similar hip fracture surgery rates but differences in care quality indicators and patterns of intracapsular fracture repair. Very high variation in total hip arthroplasty rate within both countries and higher observed early mortality in Denmark require further investigation.

PURPOSE

To explore and compare geographic variation of hip fracture surgery rate, care quality and outcomes in Ireland and Denmark.

METHODS

Patients aged ≥ 65 years with surgically treated hip fracture were included from the Irish Hip Fracture Database (years = 2017-2020, n = 12,904) and the Danish Multidisciplinary Hip Fracture Registry (years = 2016-2017, n = 12,924). The age and sex standardised rate of hip fracture surgery and the proportion of patients with seven process quality indicators, three surgery types and four outcomes were calculated. Systematic components of variation (SCV) were calculated based on hospital area (6 Irish hospital groups, 5 Danish regions).

RESULTS

The age and sex standardised rate of hip fracture surgery per 1000 older population in 2017 was 4.7 (95% CI = 4.4-5.1) in Ireland and 5.3 (95% CI = 5.1-5.5) in Denmark. Ireland had lower rates of surgery within 36 h (59% versus 84%), nutritional assessment (27% versus 84%) and pre-discharge mobility recording (52% versus 92%). Patterns of intracapsular fracture repair also differed between countries (hemiarthroplasty: Ireland = 85%, Denmark = 52%). Both countries had very high variation for total hip arthroplasty (THA) provision (SCV Ireland = 10.6, Denmark = 97.9). Ireland had longer hospital stays (median 12 versus 7 days), but lower 7-day (1.0% versus 3.1%) and 14-day (2.0% versus 5.5%) mortality.

CONCLUSION

Ireland and Denmark have similar hip fracture surgery rates, but differences in care quality, surgery patterns and outcomes. High variation in THA provision and observed differences in mortality require further exploration. In Ireland, there is scope for improvement regarding early surgery, mobility, nutrition assessment and improved post-discharge follow-up.

Isolated greater trochanter fracture may impose a comparable risk on older patients' survival as a conventional hip fracture: a population-wide cohort study

Background

Isolated greater trochanter fracture (IGT) and conventional hip fracture (HF) affect the same anatomical area but are usually researched separately. HF is associated with high mortality, and its management is well established. In contrast, IGT’s effect on mortality is unknown, and its best management strategies are unclear. This study aims to compare these patient populations, their acute- and post-acute care, physical and occupational therapy use, and up to three-year mortality.

Methods

This retrospective cohort study is based on population-wide data of Estonia, where routine IGT management is non-operative and includes immediate weight-bearing as tolerated. The study included patients aged ≥ 50 years with a validated index HF or IGT diagnosis between 2009–2017. The fracture populations’ acute- and post-acute care, one-year physical and occupational therapy use and three-year mortality were compared.

Results

A total of 0.4% (50/11,541) of included patients had an IGT. The baseline characteristics of the fracture cohorts showed a close resemblance, but the IGT patients received substantially less care. Adjusted analyses showed that the IGT patients’ acute care was 4.5 days [3.4; 5.3] shorter they had 39.2 percentage points [25.5; 52.8] lower probability for receiving post-acute care, and they had 50 percentage points [5.5: 36]] lower probability for receiving physical and occupational therapy. The IGT and HF patients’ mortality rates were comparable, being 4% and 9% for one month, 28% and 31% for one year, and 46% and 49% for three years, respectively. Crude and adjusted analyses could not find significant differences in their three-year mortality, showing a p-value of 0.6 and a hazard ratio of 0.9 [0.6; 1.3] for the IGT patients, retrospectively.

Conclusions

Despite IGT being a relatively minor injury, the evidence from this study suggests that it may impose a comparable risk on older patients’ survival, as does HF due to the close resemblance of the two fracture populations. Therefore, IGT in older patients may signify an underlying need for broad-based medical attention, ensuring need-based, ongoing, coordinated care.

Trial registration

Retrospectively registered.

Morbidity and Mortality After Second Hip Fracture With and Without Nursing Care Program

Background

Hip fractures are an increasingly common injury among older people who usually experience significantly worse mobility, independence in function, health, quality of life, and high rates of institutionalization. Studies have shown that only 40-60% of participants recover their pre-fracture level of mobility and ability to perform instrumental activities of daily living, while for those who are independent in self-care prior to the fracture, 20-60% still require assistance for various tasks one or two years after the fracture. As the cumulative incidence of a second hip fracture has been estimated to reach 8.4%, prevention of the second hip fracture is a major concern of the health system and the society focused mainly on lifestyle modifications, osteoporotic treatment, and fall-prevention strategies. The aim of the present study was to compare morbidity/mortality, functional results, and type of recovery between the first and second hip fractures in elderly patients.

Methods

Patients with a contralateral hip fracture were prospectively recruited during a three-year period (2016-2019). Level of independence, gait aids, type of rehabilitation, American Society of Anesthesiologists (ASA) physical status, Harris Hip Score (HHS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scale were evaluated at admission for the second fracture and at the last reexamination.

Results

Twenty-seven out of 33 patients, aged 87.93±6.6, underwent surgery for contralateral hip fracture and followed up for 42.52±16.46 months; the mean interval between the two fractures was 39.63 months. The HHS averaged 86.19±12.18 and 59.01±32.83 and the WOMAC 86.37±12.09 and 68.22±26.18 before and after the second fracture, respectively. The mortality rate was 37.03%, 14.8±12.93 months after the second operation, with a significant relationship between the mortality time and the interval between fractures (p=0.028). Twelve and 14 of the patients received geriatric nursing care after the first and second fracture, respectively, without significant improvement in their functional results compared to home care. Mobility of nursing care patients after the second fracture was significantly improved (p=0.019).

Conclusions

Mortality is higher in the second year after the second hip fracture and strongly correlated with the time interval between fractures. A higher possibility to return in previous mobility status occurs after geriatric nursing care. 

Shorter acute hospital length of stay in hip fracture patients after surgery predicted by early surgery and mobilization

Time to surgery, early mobilization, fracture type, and ASA grades independently affect acute hospital length of stay after hip fracture surgery. Modifiable factors can be audited to reduce length of stay, and non-modifiable factors can be used for consideration of a tiered bundled payment reimbursement model.

INTRODUCTION

As hip fracture incidence rises with our ageing global population, there will be an increase in consumption of healthcare resources. We hypothesized that hospital management and patient factors can affect healthcare burden load. Using length of stay (LOS) as a surrogate for consumption, the aim of this study is to elucidate the effect of hospital management and patient-related factors on length of stay (LOS) for patients after hip fracture surgery. We studied modifiable and non-modifiable factors influencing LOS, and identification of these modifiable factors accords opportunities for mitigating these factors.

METHODS

This retrospective study examines hip fracture data from a large tertiary hospital in Singapore over the period of 2017 to 2020. Data collected on the electronic medical record included age, gender, race, marital status, payer type, ASA score, TTS, type of surgery, fracture type, POD1 mobilization, discharge position, and presence of pressure sores, and they were correlated with LOS using binary logistic regression on SAS.

RESULTS

A total of 1045 patients were included in this study with 704 females and 341 males. The mean age was 79.5 ± 8.57 years (range 60-105) with an average LOS 13.64 ± 10.0 days (range 2-114). On binary logistic regression, ASA and trochanteric fracture remains a significant non-modifiable factor for LOS with OR = 1.486 (95% CI 1.106, 1.996, p = 0.0086) and OR 1.522 (95% CI 1.149, 2.015, p = 0.0034) respectively. Significant modifiable factors were TTS > 48 h (OR = 1.819, 95% CI 1.205, 2.746, p = 0.0044) and POD1 mobilization (OR = 0.441, 95% CI 0.257, 0.756, p = 0.0029).

CONCLUSIONS

Our analysis showed TTS and POD1 are significant modifiable factors for LOS, and resources can be diverted towards them for the management of hip fracture patients and pre-empting the increasing load on our healthcare system.

From emergency department to operating room: interventional analgesia techniques for hip fractures

PURPOSE OF REVIEW

To provide an update on pain management options with regional anesthesia for patients with hip fractures at the emergency department (ED).

RECENT FINDINGS

Patients who sustain a hip fracture are typically admitted and diagnosed in the ED before being transferred to the operating room for surgery. Studies have clearly demonstrated the ability of the fascia iliaca compartment blocks (FICBs) and femoral nerve blocks (FNBs) to reduce pain and the risk of an acute confusional state. Their administration at an early stage of the patient's trajectory in the ED is beneficial. Recent anatomical studies contributed new knowledge of nociception in the hip joint, which allowed the development of more specific infiltration analgesia techniques without muscle weakness (e.g., pericapsular hip blocks). Further research on the timing of nerve blocks and an evaluation of new motor sparing techniques is indicated.

SUMMARY

FICB and FNB are established and recommended techniques in pain management for hip fracture patients. Their use early on in the ED may improve patient comfort and outcome. Pericapsular nerve hip blocks could provide a relevant alternative in future pain management in this group of patients.

Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data

BACKGROUND

Little is known about hip fracture inpatient care in East Asia. This study examined the characteristics of patients, hospitals, and regions associated with delivery of hip fracture surgeries across Japan, Korea, and Taiwan. We also analyzed and compared how the resource use and a short-term outcome of the care in index hospitals varied according to factors in the respective health systems.

METHODS

We developed comparable, nationwide, individual-level health insurance claims datasets linked with hospital- and regional-level statistics across the health systems using common protocols. Generalized linear multi-level analyses were conducted on length of stay (LOS) and total cost of index hospitalization as well as inpatient death.

RESULTS

The majority of patients were female and aged 75 or older. The standardized LOS of the hospitalization for hip fracture surgery was 32.5 (S.D. = 18.7) days in Japan, 24.7 (S.D. = 12.4) days in Korea, and 7.1 (S.D. = 2.9) days in Taiwan. The total cost per admission also widely varied across the systems. Hospitals with a high volume of hip fracture surgeries had a lower LOS across all three systems, while other factors associated with LOS and total cost varied across countries.

CONCLUSION

There were wide variations in resource use for hip fracture surgery in the index hospital within and across the three health systems with similar social health insurance schemes in East Asia. Further investigations into the large variations are necessary, along with efforts to overcome the methodological challenges of international comparisons of health system performance.

Pre-operative epidural analgesia in hip fracture patients - A systematic review and meta-analysis

BACKGROUND

Hip fracture is a common, painful injury with increasing global incidence. Patients require optimal acute pain management. Systematic reviews have investigated the postoperative use of epidural analgesia and found that it may have advantages over systemic analgesia. It is of interest to determine whether pre-operative use of epidural analgesia is also advantageous. We conducted a systematic review and meta-analyses on the effect of epidural analgesia on pre-operative pain management in hip fracture patients.

METHODS

We included randomized controlled trials comparing pre-operatively initiated epidural analgesia with any other method of analgesia, in adults aged ≥55 years scheduled for hip fracture surgery. The main outcome was pre-operative pain at rest. Electronic searches of four medical databases were performed. Two authors independently screened for eligibility, extracted data, and assessed risk of bias. We conducted meta-analyses and assessed the certainty of the evidence by Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Three articles were included, with 179 randomized patients. All studies compared epidural analgesia with systemic analgesia, one additionally with 3-in-1-block. Meta-analyses of pre-operative pain measurements resulted in a mean difference of -5.85 95% CI [-14.90; 3.19] on a 0-100 Visual Analogue Scale with a p-value of 0.17 and a very low certainty of evidence according to the GRADE rating.

CONCLUSIONS

We did not find a difference in pre-operative pain at rest between epidural analgesia and any other method of pre-operatively initiated analgesia. The studies were few, of low quality and the difference between the two interventions remains unknown.

Mortality rates and risk factors after low-trauma hip fracture in the largest university center in Romania

We calculated in-hospital, 30-day, and 1-year mortality rates and analyzed potential mortality risk factors in 2742 patients with low-trauma hip fractures. We found a high mortality rate at 30 days and 1 year after hip fracture. The high mortality can be explained by a very high number of conservatively treated fractures.

PURPOSE

Data on mortality after low-trauma hip fracture in Romania is scarce and comes from a single-hospital study. Our aim was to calculate mortality rates and risk factors in all patients admitted for low-trauma hip fracture in the largest university medical center of Romania.

METHODS

We retrospectively analyzed the charts of all patients (>40 years old) admitted for hip fracture in a 12-month period in hospitals with an Orthopedic Department in Bucharest, Romania, and surrounding Ilfov County and calculated the crude in-hospital, 30-day, and 1-year mortality rates after low-trauma hip fractures. A number of potential clinical risk factors for mortality were evaluated.

RESULTS

We analyzed 2742 low-trauma hip fractures. The in-hospital, 30-day, and 1-year all-cause mortality rates were 4.26% (n=117), 9.59% (n=263), and 29.72% (n=815) respectively. Four hundred and fifty (16.41%) fractures were managed conservatively with a 1-year mortality HR of 3.05 (p<0.001) compared to surgically treated fractures. The 1-year mortality rate in conservatively treated fractures was 56.44% compared to 24.47% in surgically treated fractures. Age, male sex, length of stay in hospital, day of surgery, post-surgical complications, and late surgery were significantly associated (p<0.001) with mortality after hip fracture. The lowest 1-year mortality rate was in surgically treated patients with a length of stay in hospital between 6 and 10 days.

CONCLUSION

We found a high mortality rate at 30 days and 1 year after low-trauma hip fracture. The high mortality rates can be attributable, in part, to the high number of conservatively treated fractures.

What works? The association of organisational structure, reforms and interventions on efficiency in treating hip fractures

Many studies indicate huge regional and hospital-level differences in health care performance. In order to increase health system efficiency, it is important to know the reasons behind the differences and analyse the effects of those factors that can be affected by health policy. The aim of this study is to evaluate and compare various organisational factors and health policy interventions in the performance of the care of hip fracture patients in Finland. We analysed the relationship between organisational factors (hospital volume, regional concentration of treatments) and performance. The focus is also on the effects of two macro-level organisational changes (integration of production of all health and social services in one provider) and two micro-level interventions (integrated patient pathway interventions, aiming to discharge patients as soon as possible). Our results indicate that macro-level integration of the production or financing of health and social services, bigger hospital volumes, and the concentration of the acute phase of care in fewer hospitals within hospital districts were not consistently related to efficiency in the care of hip fracture patients. Instead, efficiency can be increased using micro-level interventions aiming to coordinate patient pathways at the patient group level.

Trends in Comorbidities and Complications Among Patients Undergoing Hip Fracture Repair

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.

Elderly hip fracture patients: surgical timing and factors to consider

PURPOSE OF REVIEW

Hip fractures of the elderly population are a common trauma and numbers are increasing due to ageing societies. Although this is an ordinary low energy impact injury and surgical repair techniques show good results, the perioperative course is characterized by an unparalleled disproportionate perioperative morbidity and mortality.

RECENT FINDINGS

Most studies focus on outcome-related data. Little is known on how to prevent and treat adverse sequelae, ranging from mild physical challenges to neurobiological disorders and death.

SUMMARY

Although the contribution of the anaesthetic technique per se seems to be small, the role of the anaesthesiologist as a perioperative physician is undisputed. From focusing on comorbidities and initiating preoperative optimization to intraoperative and postoperative care, there is a huge area to be covered by our faculty to ensure a reasonable outcome defined as quality of postoperative life rather than merely in terms of a successful surgical repair. Protocol-driven perioperative approaches should be employed focusing on pre, intraoperative and postoperative optimization of the patient to facilitate early repair of the fracture that may then translate into better outcomes and hence alleviate the individual patient's burden as well as the socioeconomic load for society.

Osteoporotic hip fracture mortality and associated factors in Hawai'i

The 30-day mortality of osteoporotic hip fracture patients ≥ 50 years at Hawai'i Pacific Health (2015-2016) was 4.2%. Mortality increased to 17.1% (1 year), 24.5% (2 years), and 30.1% (3 years). Increased age, male sex, higher CCI score, primary insurance status-Medicare/Medicaid, and lower BMI were associated with increased mortality.

PURPOSE

The objective of this study was to evaluate mortality and factors associated with mortality of osteoporotic hip fracture patients at community hospitals within a large healthcare system in Hawai'i.

METHODS

A retrospective chart review was conducted of 428 patients, ≥ 50 years, and hospitalized for a osteoporotic hip fracture from January 2015 to May 2016 within a large healthcare system in Hawai'i. Patient demographics, comorbidities, and treatment were collected from retrospective chart review. We determined the date of death by review of medical records and online public obituary records. We calculated 30-day, 90-day, 1-year, 2-year, and 3-year mortality after discharge for hip fracture admission. Multivariable logistic regression and proportional hazards regression were used to evaluate associations between variables and the mortality of the patients.

RESULTS

The 30-day and 90-day mortality after admission for hip fracture were 4.2% and 8.6%. One-year mortality, 2-year mortality, and 3-year mortality were 17.1%, 24.5%, and 30.1%, respectively. Through proportional hazards regression, older age (hazard ratio (HR) = 1.06, p < 0.001), high comorbidity load (HR = 1.30, p < 0.001), and primary insurance status-Medicare/Medicaid (HR = 3.78, p = 0.021) were associated with increased mortality, while female sex (HR = 0.54, p < 0.001) and higher BMI (HR = 0.94, p = 0.002) were associated with lower mortality.

CONCLUSION

After admission for osteoporotic hip fracture, the 30-day mortality was 4.2%. At 1 year, 2 years, and 3 years, mortality increased to 17.1%, 24.5%, and 30.1%, respectively. Increased age, male sex, higher Charlson comorbidity index score, primary insurance status-Medicare/Medicaid, and lower body mass index were associated with increased mortality.

Impact of an orthogeriatrician on length of stay of elderly patient with hip fracture

Hip fracture patients are complex, and orthopaedic management is limited to the surgery phase. To provide better evaluation pre-operatively and an optimal level of post-operative care, an orthogeriatrician was introduced in the orthopaedic team. This ensured that time to surgery from admission consistently was below 48 h, decreasing hospitalization time after surgery and total length of stay.

INTRODUCTION

Hip fractures are a major health issue in elderly and frail patient. The integration of orthogeriatric care within the orthopaedic team could be useful to optimize the clinical conditions of these patients in perioperative phases and stabilize them after surgery, reducing hospital length of stay. The present study evaluates the role of an orthogeriatrician in the management of patients with a hip fracture.

MATERIALS AND METHODS

Data about patients admitted and operated from February to September 2018 and from February to September 2019 were collected from the San Giovanni di Dio e Ruggi d'Aragona Hospital of Salerno database. A total of 352 patients were identified and divided in two groups according to the year in which the orthogeriatrician was working in Orthopaedic Department. Records regarding age, sex, side and type of fracture, time of admission, day of surgery and discharge were collected and length of stay, days from the admission to surgery and days from surgery to discharge were calculated.

RESULTS

There were no statistically significant differences in the pre-surgery phases of both groups, and all patients were operated at a mean of 2.1 days ± 1.8 SD from admission (p > 0.05). No statistically significant difference between demographic data in both groups (p > 0.01) was observed. There was, however, statistically significant reduction of hospitalization time after surgery and total LOS from 2018 to 2019 (p < 0.01).

CONCLUSION

An Orthogeriatric doctor in an Orthopaedic and Traumatology Department may lead a multidisciplinary approach to manage elderly patients with hip fractures, ensuring that the time to surgery from admission is less than 48 h, and reducing hospitalization time after surgery and total length of stay.

Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Sweden

Background

One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively.

Methods

We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC).

Results

The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718).

Conclusions

Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.

Analysis of mortality after hip fracture on patient, hospital, and regional level in Germany

Knowledge about risk factors of mortality after hip fracture might encourage prevention and further improvements in care. This study identified patient risk factors as well as hospital and regional characteristics associated with a decreased risk. Variation of mortality was largest on patient level and modest on hospital and regional level.

INTRODUCTION

Among numerous studies analyzing mortality as worst consequence after hip fracture, the majority focused on patient level and fewer on hospital and regional level. Comprehensive knowledge about contributing factors on all levels might help to reveal relevant inequalities, which would encourage prevention and further improvements in care. This study aimed at investigating variation of mortality after hip fracture on patient, hospital, and regional level in Germany.

METHODS

We performed a retrospective cohort study on hip fracture patients aged 65 and older using statutory health insurance claims data from Jan 2009 through Dec. 2012 and additional information from the Federal Statistical Office Germany. Regions were classified based on two-digit postal code. We applied a multilevel Cox proportional hazard model with random intercepts on hospital and regional level to investigate the risk factors for mortality within 6 and 12 months after hip fracture.

RESULTS

The dataset contained information on 123,119 hip fracture patients in 1014 hospitals in 95 German regions. Within 6/12 months, 20.9%/27.6% of the patients died. On patient level, male sex, increasing age, increased pre-fracture care level, and increasing comorbidity were associated with an increased hazard of mortality. Hospitals with increasing hip fracture volume or with orthogeriatric co-management and regions with increased population density were associated with a decreased hazard. Variation was largest on patient level and rather modest on hospital and regional level.

CONCLUSIONS

The identification of patient-related risk factors enables prognosticating mortality after hip fracture. After adjusting for those, variation seemed to be attributable rather to hospitals than to regions.

The Increase of Osteoporotic Hip Fractures and Associated One-Year Mortality in Poland: 2008-2015

INTRODUCTION

Hip fractures are a worldwide public health issue associated with significant mortality. Previous Polish studies reported an increasing trend in the number of hip fractures for both men and women, although lower than most other European countries.

MATERIALS AND METHODS

The Polish National Database was analyzed to examine osteoporotic hip fractures in the population aged 50 and over. Hip fracture incidence, rate, one-year mortality, and postoperative length of hospitalization were analyzed using the national health system data. Hospital discharge registry ICD-10 codes were reviewed from 2008 to 2015.

RESULTS

The incidence of hip fractures increased in both women and men by 19.4% and 14.2%, respectively. The female to male fracture ratio was 2.46. Mean postoperative hospitalization decreased from 13.6 to 11.2 days. The one-year mortality ranged between 30.45% to 32.8% for men and 26.2% to 28% for women. Of note, women aged 80-89 had the highest one-year mortality, 50.7%-55.4% after femoral neck fracture and 53%-58.5% after a pertrochanteric fracture.

CONCLUSIONS

Hip fractures in Poland are increasingly more prevalent in the aging population. The unfavorable trends observed in this study indicate higher annual mortality after hip fracture, compared with other European countries.

Mortality after osteoporotic hip fracture: incidence, trends, and associated factors

BACKGROUND

It is known that mortality after hip fracture increases compared to the general population; the trend in mortality is a controversial issue. The objective of this study is to examine incidence, trends, and factors associated with mortality in patients with osteoporotic hip fractures.

METHODS

This is a retrospective cohort study that uses the Registry for Hospital Discharges of the National Health System of our hospital. Patients older than 45 having an osteoporotic hip fracture between 1999 and 2015 were identified. Demographic data and comorbidities were obtained. A survival analysis was performed (Cox regression and Kaplan-Meier). Incidence rate, standardized death rate (SDR), trend (Poisson regression), and risk (hazard ratio) were calculated.

RESULTS

During 1999-2015, in our hospital, there were a total of 3992 patients admitted due to osteoporotic hip fracture. Out of these 3992 patients, 3109 patients (77.9%) were women with an average age of 84.47 years (SD 8.45) and 803 (22.1%) were men with an average age of 81.64 years (SD 10.08). The cumulative incidence of mortality was 69.38%. The cumulative mortality rate for 12 months was 33%. The annual mortality was 144.9/1000 patients/year. The 1-year mortality rate increased significantly by 2% per year (IRR 1.020, CI95% 1.008-1.033). The median overall survival was 886 days (CI95% 836-951). The probability of mortality density for a period of 10 years following a hip fracture was 16% for women and 25% for men (first 90 days). The SDR was 8.3 (CI95% 7.98-8.59). Variables that showed statistically significant association with mortality were aged over 75, masculine, institutionalization, mild to severe liver disease, chronic kidney disease, COPD, dementia, heart failure, diabetes, the Charlson Index > 2 , presence of vision disorders and hearing impairment, incontinence, and Downton scale.

CONCLUSIONS

For the last 17 years, an increase of mortality for patients with hip fracture and a higher mortality rate in men than in women were observed. Institutionalization combined with comorbidities is associated with a higher mortality.

General versus spinal anesthesia for the elderly hip fractured patient

PURPOSE OF REVIEW

There is an urge to improve care for patients with hip fracture. The present review will compare the efficacy of spinal versus general anesthesia for patients requiring hip fracture surgery.

RECENT FINDINGS

The present review gives an overview with particular emphasis on literature published during the past 24 months.

SUMMARY

So far, no clear evidence form randomized trials exists to identify the best anesthesia technique for hip fracture surgery. However, several large-scale pragmatic trials are ongoing and will provide future guidance.

Estonian hip fracture data from 2009 to 2017: high rates of non-operative management and high 1-year mortality

Background and purpose - There are no national guidelines for treatment of hip fractures in Estonia and no studies on management. We assessed treatment methods and mortality rates for hip fracture patients in Estonia. Patients and methods - We studied a population-based retrospective cohort using validated data from the Estonian Health Insurance Fund's database. The cohort included patients aged 50 and over with an index hip fracture diagnosis between January 1, 2009 and September 30, 2017. The study generated descriptive statistics of hip fracture management methods and calculated in-hospital, 1-, 3, 6-, and 12-month unadjusted all-cause mortality rates. [CrossRef] Results - 91% (number of hips: 11,628/12,731) of the original data were included after data validation. Median patient age was 81 years, 83 years for women and 74 years for men. 28% were men. Treatment methods were: total hip arthroplasty 7%; hemiarthroplasty 25%; screws 6%; sliding hip screw 25%; intramedullary nail 27%; and nonoperative management 10%. Unadjusted all-cause mortality rates for in-hospital, 1, 3, 6, and 12 months were: 3%, 9%, 18%, 24%, and 31% respectively. The 12-month mortality rate for nonoperative management was 58%. [CrossRef] Interpretation - High rates of nonoperative management and overall high 1-year mortality rates after an index hip fracture indicate the need to review exclusion criteria for surgery and subacute care in Estonia.

Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

BACKGROUND

Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

AIM

To address recent 1-year post hip fracture mortality rates in the literature.

METHODS

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

RESULTS

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

CONCLUSION

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.

Hip fracture care in Manitoba, Canada and New York State, United States: an analysis of administrative data

BACKGROUND

Nearly 30 years ago, a series of studies showed increased hip fracture mortality in Manitoba compared to the United States, but these data have not been updated. Our objective was to compare the organization of hip fracture care and short-term outcomes in Manitoba and New York State using contemporary data.

METHODS

This was a retrospective cohort study of administrative data for all adults aged 50 years or more admitted to hospital with hip fracture between Jan. 1, 2011, and Oct. 31, 2013 in Manitoba and New York State. We compared the 2 jurisdictions with respect to: 1) the proportion of hospitals treating hip fracture and annual hip fracture volume, 2) hospital length of stay, 3) death and 4) hospital readmission. We used descriptive statistics, univariate methods and regression models to compare differences in care between jurisdictions.

RESULTS

We identified 2845 patients (mean age 82.2 yr, 2061 women [72.4%]) with hip fracture in Manitoba and 31 524 patients (mean age 81.9 yr, 22 973 women [72.9%]) with hip fracture in New York. A smaller proportion of hospitals in Manitoba than in New York treated hip fracture (7/30 [23%] v. 180/239 [75.3%]) (p < 0.001); the mean annual hospital hip fracture volume was higher in Manitoba (140.0) than in New York (68.9), but the difference did not reach statistical significance (p = 0.2). For patients with femoral neck fractures, the median hospital length of stay was longer in Manitoba than in New York (13 d v. 7 d). The rate of death within 7 days of admission was similar in Manitoba and New York (1.3% v. 2.0%, p = 0.07), although the rate of in-hospital death was higher in Manitoba (5.7% v. 3.5%, p < 0.001). Readmission within 30 days of discharge was less frequent in Manitoba than in New York (9.8% v. 12.0%, p = 0.02). Results were similar for patients with intertrochanteric fractures.

INTERPRETATION

Poor short-term outcomes for patients with hip fracture in Manitoba that were documented in the 1980s seem to have been eliminated. Our results should provide optimism that reengineering of clinical care can produce substantive improvements in quality.

Determinants of mortality after hip fracture surgery in Sweden: a registry-based retrospective cohort study

Surgery for hip fractures is associated with high mortality and morbidity. The causes of poor outcome are not fully understood and may be related to other factors than the surgery itself. The relative contributions of patient, surgical, anaesthetic and structural factors have seldom been studied together. This study, a retrospective registry-based cohort study of 14 932 patients undergoing hip fracture surgery in Sweden from 1st of January 2014 to 31st of December 2016, aimed to identify important predictors of mortality post-surgery. The independent predictive power of our included variables was examined using Cox proportional hazards modeling with all-cause mortality at longest follow-up as the outcome. Twelve independent variables were considered as interrelated ‘exposures’ and their individual adjusted effect within a single model were evaluated. Kaplan-Meier curves were also generated. Crude mortality rates were 8.2% at 30 days (95% CI 7.7–8.6%) and 23.6% at 365 days (95% CI 22.9–24.2%). Of the 12 factors entered into the Cox regression analysis, age (aHR1.06, p < 0.001), male gender (aHR 1.45, p < 0.001), ASA-PS-class (ASA 1&2 reference; ASA 3 aHR 2.12; ASA 4 aHR 4.79; ASA 5 aHR 12.57 respectively, p < 0.001) and PACU-LOS (aHR 1.01, p < 0.001) were significantly associated with mortality at longest follow-up (up to 3 years). University hospital status was protective (aHR 0.83, p < 0.001) in the same model. Age, gender and ASA-PS-class were strong predictors of mortality after surgery for hip fractures in Sweden. University hospital status and length of stay in the postoperative care unit were also identified as modifiable risk factors after multivariable adjustment and require confirmation in future studies.

Improve hip fracture outcome in the elderly patient (iHOPE): a study protocol for a pragmatic, multicentre randomised controlled trial to test the efficacy of spinal versus general anaesthesia

INTRODUCTION

Hip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse.

METHODS AND ANALYSIS

The iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60. ETHICS AND DISSEMINATION: iHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00013644; Pre-results.

The independent patient factors that affect length of stay following hip fractures

Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.

A comparison of outcomes between Canada and the United States in patients recovering from hip fracture repair: secondary analysis of the FOCUS trial

Objective

To determine if adjusted mortality, walking ability or return home differed after hip fracture surgery between Canada and the USA.

Design

Secondary analysis of the Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS) trial data.

Setting

Data were collected from 47 American and Canadian hospitals.

Participants

Overall, 2016 subjects with a hip fracture (USA = 1222 (60.6%); Canada = 794 (39.4%)) were randomized to a liberal or restrictive transfusion strategy. Subjects were 50 years and older, with cardiovascular disease and/or risk factors and hemoglobin <100 g/L within 3 days post-surgery. The average age was 82 years and 1527(76%) subjects were females.

Intervention

Demographics, health status and health services data were collected up to 60 days post-surgery and mortality to a median of 3 years post-surgery.

Main outcomes

Mortality, inability to walk and return home.

Results

US subjects had higher adjusted mortality than Canadians at 30 days (odds ratio = 1.78; 95% confidence interval: 1.09-2.90), 60 days (1.53; 1.02-2.29) and up to 3 years (hazard ratio = 1.25; 1.07-1.45). There were no differences in adjusted outcomes for walking ability or return home at 30 or 60 days post-surgery. Median hospital length of stay was longer (P < 0.0001) in Canada (9 days; interquartile range: 5-18 days) than the US (3 days; 2-5 days). US subjects (52.9%) were more likely than Canadians (16.8%) to be discharged to nursing homes for rehabilitation (P < 0.001).

Conclusions

Adjusted survival favored Canadians post hip fracture while walking ability and return home were not different between countries. The reason(s) for mortality differences warrant further investigation.

Greater rate of cephalic screw mobilisation following proximal femoral nailing in hip fractures with a tip-apex distance (TAD) and a calcar referenced TAD greater than 25 mm

Background

To ascertain whether the tip–apex distance (TAD), calcar referenced TAD (CalTAD), and the sum of both (TADcalTAD) are predictive measurements of mobilisation of the cephalic screw in patients with trochanteric hip fractures.

Methods

Between 2014 and 2015, 68 patients (mean age 86 years, 45 females, 23 males) with a trochanteric hip fracture underwent intramedullary nailing. The TAD and CalTAD were measured, and for each parameter, we calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

Results

There is evidence of a statistically significant association between a TAD and CalTAD greater than 25 mm and a TADcalTAD greater than 50 mm and mobilisation of the cephalic screw. All measurements have similar sensitivity, but the TAD presents the highest specificity (p < 0.01).

Conclusion

To avoid the risk of mobilisation of the cephalic screw and possible subsequent failure of the construct, surgeons should strive for a TAD and CalTAD less than 25 mm and a TADcalTAD less than 50 mm when using intramedullary fixation.

Influence of a New "Call-Out Algorithm" for Management of Postoperative Pain and Its Side Effects on Length of Stay in Hospital: A Two-Centre Prospective Randomized Trial

Background

We recently introduced the efficacy safety score (ESS) as a new “call-out algorithm” for management of postoperative pain and side effects. In this study, we report the influence of ESS recorded hourly during the first 8 hours after surgery on the mobility degree, postoperative nonsurgical complications, and length of hospital stay (LOS).

Methods

We randomized 1152 surgical patients into three groups for postoperative observation: (1) ESS group (n = 409), (2) Verbal Numeric Rate Scale (VNRS) for pain group (n = 417), and (3) an ordinary qualitative observation (Control) group (n = 326). An ESS > 10 or VNRS > 4 at rest or a nurse's observation of pain or adverse reaction to analgesic treatment in the Control group served as a “call-out alarm” for an anaesthesiologist.

Results

We found no significant differences in the mobility degree and number of postoperative nonsurgical complications between the groups. LOS was significantly shorter with 12.7 ± 6.3 days (mean ± SD) in the ESS group versus 14.2 ± 6.2 days in the Control group (P < 0.001).

Conclusion

Postoperative ESS recording in combination with the possibility to call upon an anaesthesiologist when exceeding the threshold score might have contributed to the reductions of LOS in this two-centre study. This trial is registered with NCT02143128.

General vs. neuraxial anaesthesia in hip fracture patients: a systematic review and meta-analysis

BACKGROUND

Hip fracture is a trauma of the elderly. The worldwide number of patients in need of surgery after hip fracture will increase in the coming years. The 30-day mortality ranges between 4 and 14%. Patients' outcome may be improved by anaesthesia technique (general vs. neuraxial anaesthesia). There is a dearth of evidence from randomised studies regarding to the optimal anaesthesia technique. However, several large non-randomised studies addressing this question have been published from the onset of 2010.

METHODS

To compare the 30-day mortality rate, in-hospital mortality rate and length of hospital stay after neuraxial (epidural/spinal) or general anaesthesia in hip fracture patients (≥ 18 years old) we prepared a systematic review and meta-analysis. A systematic search for appropriate retrospective observational and prospective randomised studies in Embase and PubMed databases was performed in the time-period from 01.01.2010 to 21.11.2016. Additionally a forward searching in google scholar, a level one reference list searching and a formal searching of trial registries was performed.

RESULTS

Twenty retrospective observational and three prospective randomised controlled studies were included. There was no difference in the 30-day mortality [OR 0.99; 95% CI (0.94 to 1.04), p = 0.60] between the general and the neuraxial anaesthesia group. The in-hospital mortality [OR 0.85; 95% CI (0.76 to 0.95), p = 0.004] and the length of hospital stay were significantly shorter in the neuraxial anaesthesia group [MD -0.26; 95% CI (-0.36 to -0.17); p < 0.00001].

CONCLUSION

Neuraxial anaesthesia is associated with a reduced in-hospital mortality and length of hospitalisation. However, type of anaesthesia did not influence the 30-day mortality. In future there is a need for large randomised studies to examine the association between the type of anaesthesia, post-operative complications and mortality.

Anchorage strategies in geriatric hip fracture management

There is an enormous humanitarian and socioeconomic need to improve the quality and effectiveness of care for patients with hip fracture. To reduce mechanical complications in the osteosynthesis of proximal femoral fractures, improved fixation techniques have been developed including blade or screw-anchor devices, locked minimally invasive or cement augmentation strategies. However, despite numerous innovations and advances regarding implant design and surgical techniques, systemic and mechanical complication rates remain high. Treatment success depends on secure implant fixation in often-osteoporotic bone as well as on patient-specific factors (fracture stability, bone quality, comorbidity, and gender) and surgeon-related factors (experience, correct reduction, and optimal screw placement in the head/neck fragment). For fracture fixation, the anchorage of the lag screw within the femoral head plays a crucial role depending on the implant's design. Meta-analyses and randomized controlled studies demonstrate that there is a strong trend towards arthroplasty treating geriatric femoral neck fractures. However, for young adults as well as older patients with less compromised bone quality, or in undisplaced fractures, head-preserving therapy is preferred as it is less invasive and associated with good functional results. This review summarizes the evidence for the internal fixation of femoral neck fractures and trochanteric femoral fractures in elderly patients. In addition, biomechanical considerations regarding implant anchorage in the femoral head including rotation, migration, and femoral neck shortening are made. Finally, cement augmentation strategies for hip fracture implants are evaluated critically.

Costs and Quality at the Hospital Level in the Nordic Countries

This article develops and analyzes patient register-based measures of quality for the major Nordic countries. Previous studies show that Finnish hospitals have significantly higher average productivity than hospitals in Sweden, Denmark, and Norway and also a substantial variation within each country. This paper examines whether quality differences can form part of the explanation and attempts to uncover quality-cost trade-offs. Data on costs and discharges in each diagnosis-related group for 160 acute hospitals in 2008-2009 were collected. Patient register-based measures of quality such as readmissions, mortality (in hospital or outside), and patient safety indices were developed and case-mix adjusted. Productivity is estimated using bootstrapped data envelopment analysis. Results indicate that case-mix adjustment is important, and there are significant differences in the case-mix adjusted performance measures as well as in productivity both at the national and hospital levels. For most quality indicators, the performance measures reveal room for improvement. There is a weak but statistical significant trade-off between productivity and inpatient readmissions within 30 days but a tendency that hospitals with high 30-day mortality also have higher costs. Hence, no clear cost-quality trade-off pattern was discovered. Patient registers can be used and developed to improve future quality and cost comparisons.

A Window on Geographic Variation in Health Care: Insights from EuroHOPE

The aim of EuroHOPE was to provide new evidence on the performance of healthcare systems, using a disease-based approach, linkable patient-level data and internationally standardized methods. This paper summarizes its main results. In the seven EuroHOPE countries, the Acute Myocardial Infarction (AMI), stroke and hip fracture patient populations were similar with regard to age, sex and comorbidity. However, non-negligible geographic variation in mortality and resource use was found to exist. Survival rates varied to similar extents between countries and regions for AMI, stroke, hip fracture and very low birth weight. Geographic variation in length of stay differed according to type of disease. Regression analyses showed that only a small part of geographic variation could be explained by demand and supply side factors. Furthermore, the impact of these factors varied between countries. The findings show that there is room for improvement in performance at all levels of analysis and call for more in-depth disease-based research. In using international patient-level data and a standardized methodology, the EuroHOPE approach provides a promising stepping-stone for future investigations in this field. Still, more detailed patient and provider information, including outside of hospital care, and better data sharing arrangements are needed to reach a more comprehensive understanding of geographic variations in health care.