1
|
Smolle MA, Fischerauer SF, Vukic I, Leitner L, Puchwein P, Widhalm H, Leithner A, Sadoghi P. 30-day and one-year readmission rate in 11,270 patients with surgical treatment for proximal femoral fractures across Austria. Bone Jt Open 2024; 5:294-303. [PMID: 38599585 PMCID: PMC11007600 DOI: 10.1302/2633-1462.54.bjo-2024-0002.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: 04/12/2024] Open
Abstract
Aims Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria. Methods Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated. Results The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications. Conclusion Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population.
Collapse
Affiliation(s)
- Maria A. Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
- Department of Orthopaedics, Balgrist University Hospital, Zurich, Switzerland
| | | | - Ines Vukic
- Federal Ministry of Social Affairs, Health, Care and Consumer Protection, Vienna, Austria
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Paul Puchwein
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Harald Widhalm
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| |
Collapse
|
2
|
Ek S, Meyer AC, Wennberg A, Greve K, Hedström M, Modig K. A short length of hospital stay is not associated with risk of readmission among hip fracture patients - a Swedish national register-based cohort study. BMC Geriatr 2023; 23:744. [PMID: 37968577 PMCID: PMC10648637 DOI: 10.1186/s12877-023-04464-2] [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: 03/01/2023] [Accepted: 11/07/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Hospital length of stay (LoS) after a hip fracture likely mirrors health status; however, a too short hospitalization might increase the risk of readmission. In this national register-based study, we investigated the association between LoS after a hip fracture and the risk of readmissions. METHODS 73,551 patients with a first hip fracture between 2012 and 2019 were followed for 4 months after discharge. LoS was categorized by cubic splines and the association with readmissions was analyzed with Cox regression models. RESULTS The mean LoS was 11 ± 6 days and 25% of the study population had at least one readmission. Compared to the mean LoS of 9-12 days, there was a 18% decreased risk of readmission for LoS of 2-4 days (HR 0.82 [95% CI 0.77-0.87]) and 13% decrease for 5-8 days (HR 0.87 [95% CI 0.83-0.91]), when adjusting for sex, age, walking ability, ASA score, CCI, complications during hospitalization and living arrangements. For longer LoS, risk of readmission increased (13-23 days: HR 1.09 [95% CI 1.05-1.13] and 24 + days: HR 1.19 [95% CI 1.11-1.28]). The results were robust across sex, age, and living arrangements. The most common specific reasons for readmission were trauma/injury, cardiovascular and complications, and the proportions did not differ considerably between short and long LoS-categories. CONCLUSIONS While a long LoS can be explained by the care need of the patient, a short LoS - compared to the average stay - does not increase the risk of readmission regardless of health status and hospital complications in a Swedish setting.
Collapse
Affiliation(s)
- Stina Ek
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Anna C Meyer
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Wennberg
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Greve
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
| | - Margareta Hedström
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Trauma and Reparative Medicine Theme (TRM), Karolinska University Hospital, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
3
|
Correoso Castellanos S, Blay Domínguez E, Veracruz Gálvez EM, Muela Pérez B, Puertas García-Sandoval JP, Ricón Recarey FJ, Salinas Gilabert JE, Mira Viudes V, Lajara Marco F. [Translated article] Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:T365-T370. [PMID: 37364723 DOI: 10.1016/j.recot.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/08/2023] [Indexed: 06/28/2023] Open
Abstract
INTRODUCTION Pre-operative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge. MATERIAL AND METHODS A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA≤II were included for analysis and divided according to their post-operative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year post-operative mortality rates; 30-day post-operative hospital readmission rate; and medical or surgical cause were recorded. RESULTS In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% versus 4.1%, p=.16) and 1-year post-operative (4.3% versus 16.3%, p=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% versus 16.3%, p=.037). CONCLUSIONS In the present study, the early discharge group obtained better results 30-day and 1-year post-operative mortality indicators, as well as readmission for medical reasons.
Collapse
|
4
|
Correoso Castellanos S, Blay Domínguez E, Veracruz Gálvez EM, Muela Pérez B, Puertas García-Sandoval JP, Ricón Recarey FJ, Salinas Gilabert JE, Mira Viudes V, Lajara Marco F. Lower mortality and readmission in patients with few comorbidities who underwent hip fracture surgery and were discharged early. Rev Esp Cir Ortop Traumatol (Engl Ed) 2023; 67:365-370. [PMID: 36801250 DOI: 10.1016/j.recot.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Preoperative delay in patients with hip fracture surgery (HF) has been associated with poorer outcomes; however, the optimal timing of discharge from hospital after surgery has been little studied. The aim of this study was to determine mortality and readmission outcomes in HF patients with and without early hospital discharge. MATERIAL AND METHODS A retrospective observational study was conducted selecting 607 patients over 65years of age with HF intervened between January 2015 and December 2019, from which 164 patients with fewer comorbidities and ASA ≤II were included for analysis and divided according to their postoperative hospital stay into early discharge or stay ≤4 days (n=115), and non-early or post-operative stay >4days (n=49). Demographic characteristics; fracture and surgical-related characteristics; 30-day and one-year postoperative mortality rates; 30-day postoperative hospital readmission rate; and medical or surgical cause were recorded. RESULTS In the early discharge group all outcomes were better compared to the non-early discharge group: lower 30-day (0.9% vs 4.1%, P=.16) and 1-year postoperative (4.3% vs 16.3%, P=.009) mortality rates, as well as a lower rate of hospital readmission for medical reasons (7.8% vs 16.3%, P=.037). CONCLUSIONS In the present study, the early discharge group obtained better results 30-day and 1-year postoperative mortality indicators, as well as readmission for medical reasons.
Collapse
|
5
|
Domingue G, Warren D, Koval KJ, Riehl JT. Complications of Hip Hemiarthroplasty. Orthopedics 2023; 46:e199-e209. [PMID: 36719411 DOI: 10.3928/01477447-20230125-06] [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] [Indexed: 02/01/2023]
Abstract
Hip hemiarthroplasty is a commonly performed orthopedic surgery, used to treat proximal femur fractures in the elderly population. Although hip hemiarthroplasty is frequently successful in addressing these injuries, complications can occur. Commonly seen complications include dislocation, periprosthetic fracture, acetabular erosion, and leg-length inequality. Less frequently seen complications include neurovascular injury and capsular interposition. This article presents a comprehensive review of the complications associated with the management of hip hemiarthroplasty. [Orthopedics. 2023;46(4):e199-e209.].
Collapse
|
6
|
Tian M, Wang Z, Zhu Y, Tian Y, Zhang K, Li X. Incidence, Causes, and Risk Factors of Unplanned Readmissions in Elderly Patients Undergoing Hip Fracture Surgery: An Observational Study. Clin Interv Aging 2023; 18:317-326. [PMID: 36883190 PMCID: PMC9985873 DOI: 10.2147/cia.s395012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/17/2023] [Indexed: 03/03/2023] Open
Abstract
Aim The purpose of this study was to examine the incidence and cause of unplanned readmission after Surgically Treated Hip Fractures in Elderly Patients and identify the associated risk factors. Methods This study retrospectively collected the data on elderly patients who underwent hip fracture surgery at two institutions from January 2020 to December 2021, and identified those who were readmitted within 12 months postoperatively. Based on the presence or not of postoperative readmission, they were divided into readmission and non-readmission groups. Demographics, surgery-related variables, and laboratory parameters were compared between groups. The specific causes for documented readmission were collected and summarized. Multivariate logistic regression analysis was performed to identify the associated risk factors. Results There were 930 patients including 76 (8.2%) patients who were readmitted within 12 months postoperatively. Overall, cardiac and respiratory complications and new-onset fractures were the first three common causes of readmission, taking an overwhelming proportion of 53.9% (41/76). Over 60% (61.8%, 47/76) of readmissions occurred within 30 days after surgery, with medical complications taking a predominance (89.4%, 42/47). New-onset fractures accounted for a proportion of 18.4% (14/76), occurring at different time points; especially, at 90-365 days, it accounted for 44.4% (8/18). Multivariate analysis revealed that age ≥80 years (OR, 1.0, 95% CI, 1.0 to 1.1; P=0.032), preoperative albumin level ≤21.5 g/L (OR, 1.1, 95% CI, 1.0 to 1.2; P=0.009), the postoperative occurrence of DVT (OR, 4.2, 95% CI, 2.5 to 7.2; P=0.001), and local anesthesia (OR, 2.1, 95% CI, 1.1 to 4.0; P=0.029) were independent risk factors for unplanned readmissions. Conclusion This study identified several risk factors for unplanned readmissions after elderly hip fractures, and provided detailed information about unplanned readmissions.
Collapse
Affiliation(s)
- Miao Tian
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Zhijia Wang
- Department of Joint Surgery, Huai 'an Hospital of Huai'an City, Huai'an, People's Republic of China
| | - Yanbin Zhu
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China.,Hebei Orthopedic Research Institute, Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, People's Republic of China
| | - Yunxu Tian
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Kexin Zhang
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Xiuting Li
- Department of Orthopedic Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| |
Collapse
|
7
|
Active clinical issues at discharge predict readmission within 30 days and one year following hip fracture surgery. Eur Geriatr Med 2022; 13:1477-1486. [PMID: 36284053 DOI: 10.1007/s41999-022-00707-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
AIM To investigate the impact of delay in surgery for medical causes and active clinical issues (ACIs) on 30-day readmission for medical causes after hip fracture surgery. FINDINGS ACIs were associated with readmissions following hip fracture surgery; however, no association between readmissions and reasons for delaying surgery was found. MESSAGE Further studies into ACIs and reasons for delaying surgery are warranted to make more tailor-made treatment plans for patients with hip fracture.
Collapse
|
8
|
Predictors of hospital readmission after fractures: One-year follow-up study. Injury 2022; 53:3220-3226. [PMID: 35811152 DOI: 10.1016/j.injury.2022.06.018] [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: 09/28/2021] [Revised: 06/04/2022] [Accepted: 06/12/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Identify the incidence and predictive factors for readmissions of elderly hospitalized with fractures. METHOD Prospective cohort study on 376 elderly people from a trauma referral large hospital in central Brazil. Data were collected from medical records of elderly people with radiological diagnosis of fractures. Readmission that occurs up to one year after the first discharge was defined the outcome variable. Pre- and post-admission characteristics were analyzed as predictive factors. Multiple analysis was performed using robust Poisson regression. RESULTS The main cause of hospitalization was fracture of the femur (53.2%) and the most frequent trauma mechanism was fall from standing height (72.9%). The incidence of readmission was 20.7%, of which 30.5% were related to the fracture itself, with emphasis on Surgical Site Infection. The predictors of readmissions were: age range 60 to 69 years, COPD, delirium and fracture of the femur. CONCLUSIONS The incidence of readmissions was high, with various causes and associated conditions pre-admission (age range 60-69, presenting COPD) and post-admission (delirium). The monitoring of these factors in the hospital environment is essential for prevention of readmissions.
Collapse
|
9
|
Fu M, Guo J, Zhang Y, Zhao Y, Zhang Y, Hou Z, Wang Z. Effect of integrated management bundle on 1-year overall survival outcomes and perioperative outcomes in super elderly patients aged 90 and over with hip fracture: non-concurrent cohort study. BMC Musculoskelet Disord 2022; 23:778. [PMID: 35971104 PMCID: PMC9377134 DOI: 10.1186/s12891-022-05720-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to concomitant factors like frailty and comorbidity, super elderly (≥90 years) patients with hip fracture differ from patients aged 65-89 years in perioperative complications and mortality. The integrated management bundle referred to bundled application of multiple clinical measures. The aim of this study was to analyze effect of integrated management bundle on 1-year overall survival and perioperative outcomes in super elderly patients with hip fracture, with multidisciplinary management group serving as the control group. METHODS In this retrospective cohort study, super elderly patients with hip fracture were included from Jan 2017 to Nov 2020. Patients were retrospectively divided to multidisciplinary management group and integrated management bundle group. The primary outcome was 1- year overall survival, and the secondary outcome was perioperative outcomes. Kaplan-Meier methods was used to compare survival probability. Multivariable Cox's modeling was used to explain the effect of integrated bundle on 1-year overall survival adjusted for confounders. The perioperative outcomes including complications and in-hospital data of two groups were compared. The multivariable logistic regression was used to explain the effect of integrated bundle on the occurrence of perioperative complications adjusted for confounders. Prognostic factors related to survival was identified by multivariable Cox's regression analysis. RESULTS Ninety-seven patients comprised multidisciplinary management group, and 83 comprised integrated management bundle group. The Kaplan-Meier plots showed that the survival probability of integrated management bundle group was significantly better than multidisciplinary management group (HR:0.435, 95%CI:0.207-0.914, P = 0.039). Multivariable analysis after adjustment for confounders showed a 42.8% lower incidence of mortality integrated management bundle group than multidisciplinary management group (HR:0.428, 95%CI:0.186-0.986, P = 0.046). Incidence of hypoproteinemia, and electrolyte disturbance in integrated management bundle group was significantly lower than multidisciplinary management group (all P < 0.05). In addition, significant reduction was observed in length of stay (P < 0.05) in integrated management bundle group. Multivariable logistic regression showed integrated management bundle was independent protective factor of hypoproteinemia, and electrolyte disturbance. mECM score ≥ 6 and ASA score > 2 were independent risk factors of overall survival (HR: 1.940, 95%CI: 1.067-3.525,P = 0.030; HR: 2.281, 95%CI: 1.113-4.678,P = 0.024). CONCLUSIONS The integrated management bundle improved 1-year overall survival and played positive effects in improving perioperative outcomes. It might be a more suitable management modality for super elderly patients with hip fracture.
Collapse
Affiliation(s)
- Mingming Fu
- Department of Geriatric Orthopedics, Third Hospital of Hebei Medical University, Hebei, 050051, Shijiazhuang, People's Republic of China
| | - Junfei Guo
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People's Republic of China
| | - Yaqian Zhang
- Department of Geriatric Orthopedics, Third Hospital of Hebei Medical University, Hebei, 050051, Shijiazhuang, People's Republic of China
| | - Yuqi Zhao
- Department of Geriatric Orthopedics, Third Hospital of Hebei Medical University, Hebei, 050051, Shijiazhuang, People's Republic of China
| | - Yingze Zhang
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People's Republic of China.,NHC Key Laboratory of Intelligent Orthopedic Equipment (The Third Hospital of Hebei Medical University), Hebei, 050051, Shijiazhuang, People's Republic of China.,Chinese Academy of Engineering, Beijing, 100088, People's Republic of China
| | - Zhiyong Hou
- Department of Orthopedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050051, People's Republic of China. .,NHC Key Laboratory of Intelligent Orthopedic Equipment (The Third Hospital of Hebei Medical University), Hebei, 050051, Shijiazhuang, People's Republic of China.
| | - Zhiqian Wang
- Department of Geriatric Orthopedics, Third Hospital of Hebei Medical University, Hebei, 050051, Shijiazhuang, People's Republic of China.
| |
Collapse
|
10
|
Kanazawa N, Inoue N, Tani T, Naito K, Horiguchi H, Fushimi K. Implementation of Rehabilitation and Patient Outcomes During the Initial COVID-19 Pandemic. Prog Rehabil Med 2022; 7:20220031. [PMID: 35814717 PMCID: PMC9225958 DOI: 10.2490/prm.20220031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives: This study investigated the impact of the initial outbreak of coronavirus disease
(COVID-19) on rehabilitation and functional outcomes of patients in Japanese
hospitals. Methods: The study subjects were hospitals belonging to Japan’s National Hospital Organization
that provided inpatient care for patients with coronavirus COVID-19 during March–May
2020. We specifically focused on patients who were hospitalized for acute diseases, such
as stroke, hip fracture, acute myocardial infarction, congestive heart failure, or
chronic obstructive pulmonary disease, and received rehabilitation during
hospitalization. Data were sourced from Japanese administrative data. The primary
outcome was rehabilitation provision time in the target hospitals. The secondary
outcomes were patient outcomes: rehabilitation participation time, length of hospital
stay, 30-day readmission rate, and improvement of activities of daily living.
Interrupted time series analysis was performed to evaluate the trend of rehabilitation
provision time. Patient outcomes were compared with those for 2019. Results: The rehabilitation provision time for outpatients declined by 62% during the pandemic,
while that for inpatients declined temporarily, and then increased. Compared with 2019
outcomes, rehabilitation participation time was longer and hospital stay length was
shorter for stroke and hip-fracture patients, the 30-day readmission rate was increased
for hip-fracture patients, and improvement of activities in daily living was less for
patients with congestive heart failure who were totally dependent at admission. Other
outcomes did not change. Conclusions: The findings suggest that during the initial COVID-19 pandemic, resources for
rehabilitation were quickly reallocated to inpatient care, and the impact on inpatient
outcomes was minimized.
Collapse
Affiliation(s)
- Natsuko Kanazawa
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization, Tokyo, Japan
| | - Norihiko Inoue
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuaki Tani
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization, Tokyo, Japan
| | - Koichi Naito
- Department of Physical Therapy, Faculty of Medical Sciences, Nagoya Women’s University, Nagoya, Japan
| | - Hiromasa Horiguchi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Clinical Data Management and Research, Clinical Research Center, National Hospital Organization, Tokyo, Japan
| |
Collapse
|
11
|
Meyer AC, Eklund H, Hedström M, Modig K. The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture - A nationwide cohort study. Osteoporos Int 2021; 32:2185-2192. [PMID: 34013459 PMCID: PMC8563539 DOI: 10.1007/s00198-021-05956-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 12/05/2022]
Abstract
UNLABELLED This study examines the association between the ASA physical status classification score at hip fracture surgery and severe postoperative complications in patients aged 60 and older. Among both men and women, ASA scores consistently predict a wide range of complications including infections, cardiovascular complications, hospital readmissions, and death. INTRODUCTION Hip fractures are common in aging populations and associated with poor prognosis. This study examines how the American Society of Anaesthesiologists (ASA) physical status classification is related to severe complications among hip fracture patients including infections, cardiovascular diseases, hospital readmissions, and death. METHODS Based on a linkage of the Swedish National Inpatient Register with the Swedish National Registry for Hip Fractures (RIKSHÖFT), this study includes patients aged 60+ with first hip fracture between 1998 and 2017. We estimated associations between ASA score and complications during the hospital stay and during 1 year after hip fracture using multivariable-adjusted logistic regression and Cox proportional hazard regression. RESULTS The study population included 170,193 hip fracture patients of which 24% died and 39% were readmitted to hospital within 1 year. The most common complications were urinary tract infections, pneumonia, second hip fractures, and heart failure. Among both men and women, higher ASA scores were consistently associated with higher risks for all complications included in this study. The strongest associations were observed for heart failure, myocardial infarction, pneumonia, and death. CONCLUSION ASA scores are routinely assessed in clinical practice and predict a wide range of postoperative complications among hip fracture patients. Since many complications may be preventable through adequate drug treatment, rehabilitation, and risk awareness, future studies should examine the mechanisms linking ASA scores to complication risk in order to improve preventive strategies. Particularly, the high risk of cardiovascular complications among patients with high ASA scores deserves clinical and scientific attention.
Collapse
Affiliation(s)
- A C Meyer
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, PO Box 210, SE-17177, Stockholm, Sweden.
| | - H Eklund
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, PO Box 210, SE-17177, Stockholm, Sweden
| | - M Hedström
- Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska Institutet, SE-17177, Stockholm, Sweden
- Department of Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - K Modig
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, PO Box 210, SE-17177, Stockholm, Sweden
| |
Collapse
|
12
|
Liu K, Sheng J, Zhang H, Liu L, Tang Y, Zhu Z, Qiao L, Sun Z, Yao Y. Risk Factors for Mortality After Uncemented Bipolar Hemiarthroplasty for Geriatric Displaced Femoral Neck Fracture. Orthopedics 2021; 44:e570-e576. [PMID: 34292818 DOI: 10.3928/01477447-20210618-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Uncemented bipolar hemiarthroplasty (UBHA) has been widely used to treat geriatric displaced femoral neck fracture (GDFNF), which results in a high 30-day mortality rate among the elderly. To date, few studies have focused on the risk factors for mortality after UBHA for GDFNF. In this retrospective study, elderly patients (age ≥70 years) who underwent UBHA for GDFNF were studied in order to provide helpful insight into the risk factors for mortality postoperatively. This retrospective study enrolled 835 elderly patients who underwent UBHA for GDFNF from January 2010 to December 2017. The Kaplan-Meier method and Cox regression analysis were used to identify significant risk factors predicting mortality after UBHA for GDFNF. Univariate analysis showed that underweight (body mass index <18.5 kg/m2), smoking, alcohol use, hypertension, chronic kidney disease, hypoproteinemia, low activities of daily living (ADL) score (0 to 2), and postoperative delirium were identified as the potential risk factors responsible for mortality after UBHA for GDFNF. Multivariate analysis suggested that underweight, hypoproteinemia, low ADL score, and postoperative delirium were significant risk factors predicting mortality after UBHA for GDFNF. Postoperative delirium was the most robust risk factor for mortality after UBHA for GDFNF. Underweight, hypoproteinemia, and low ADL score were also closely associated with mortality after UBHA for GDFNF. [Orthopedics. 2021;44(4):e570-e576.].
Collapse
|
13
|
Do VQ, Draper B, Harvey L, Driscoll T, Braithwaite J, Brodaty H, Mitchell R. Examining trajectories of hospital readmission in older adults hospitalised with hip fracture from residential aged care and the community. Arch Osteoporos 2021; 16:120. [PMID: 34405278 DOI: 10.1007/s11657-021-00966-x] [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: 12/08/2020] [Accepted: 05/06/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fracture trajectories have not been examined for older adults in aged care or living in the community. Trajectories of health care use were defined by distinct predictive factors. These results can inform the development of targeted strategies to reduce health service use following hip fracture. OBJECTIVE To examine hospital service use trajectories of older adults who were hospitalised for hip fracture and living in a residential aged care facility (RACF) or the community, and to identify factors predictive of trajectory group membership. These findings may inform future programmes aimed at reducing unexpected hospitalisations and subsequently reduce health care costs. METHODS A group-based trajectory analysis of hospitalisations was conducted for adults aged ≥ 65 years hospitalised for hip fracture during 2008-2009 in New South Wales, Australia. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived for RACF and community-dwelling older adults based on the number of subsequent hospital admissions following the index hip fracture. Multinomial logistic regression examined predictors of trajectory group membership for subsequent hospital admissions. RESULTS There were 5752 hip fracture hospitalisations, with two-thirds of hip fractures occurring in community-dwellers. Key predictors of trajectory group membership for both RACF residents and community-dwellers were age group, sex, hospital length of stay and cognitive impairment. Assistance with activities of daily living and complex health care needs were also predictive of group membership in RACF residents. Location of residence and time to move to a RACF were additional predictors of group membership for community-dwellers. CONCLUSION Health service use trajectories differed for RACF residents and community-dwellers; however, there were similar patient characteristics that defined trajectory group membership. Low users of hospital services living in RACFs or the community included older adults with generally unfavourable health conditions, potentially indicating that palliative care or advanced care directives and community-care initiatives, respectively, have played a part in the lowered frequency of rehospitalisation.
Collapse
Affiliation(s)
- Vu Quang Do
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia.
| | - Brian Draper
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Dementia Centre for Research Collaboration - Assessment and Better Care, University of New South Wales, Sydney, Australia
| | - Lara Harvey
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia.,Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Tim Driscoll
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia
| | - Henry Brodaty
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.,Dementia Centre for Research Collaboration - Assessment and Better Care, University of New South Wales, Sydney, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie Park, NSW, 2109, Australia
| |
Collapse
|
14
|
Haugan K, Klaksvik J, Foss OA. 30-day mortality in patients after hip fracture surgery: A comparison of the Charlson Comorbidity Index score and ASA score used in two prediction models. Injury 2021; 52:2379-2383. [PMID: 33581871 DOI: 10.1016/j.injury.2021.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/02/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologists (ASA) Physical Status Classification used in two prediction models for 30-day mortality after hip fracture surgery. STUDY DESIGN AND SETTING Data from 3651 patients (mean age: 83 years) from a Norwegian University Hospital were retrospectively obtained and randomly divided into two cohorts: a model cohort (n = 1825) to develop two prediction models with CCI and ASA as the main predictors, and a validation cohort (n = 1826) to assess the predictive ability of both models. A receiver operating characteristic (ROC) curve determined the best model to predict mortality. RESULTS Area under the ROC curve at 30 days was 0.726 (p = 0.988) for both the CCI- and ASA-model. The chosen cut-off-points on the ROC curve for CCI- and ASA-model corresponded to similar model sensitivities of 0.657 and specificities of 0.680 and 0.679, respectively. Hence, each model predicts correctly 66% (n = 96) of the mortalities and 68% (n = 1132 and n = 1131) of the survivals. 23% (n = 33) of the mortalities were predicted by neither model. CONCLUSION The CCI- and ASA-model had equal predictive ability of 30-day mortality after hip fracture. Considering the effort involved in calculating Charlson Comorbidity Index score, the ASA score may be the preferred tool to predict the 30-day mortality after hip fracture.
Collapse
Affiliation(s)
- Kristin Haugan
- Orthopaedic Department, Orthopaedic Research Centre, St.Olavs Hospital, Trondheim University Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway; Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Faculty of Medicine and Health Sciences, N-7491 Trondheim, Norway.
| | - Jomar Klaksvik
- Orthopaedic Department, Orthopaedic Research Centre, St.Olavs Hospital, Trondheim University Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway
| | - Olav A Foss
- Orthopaedic Department, Orthopaedic Research Centre, St.Olavs Hospital, Trondheim University Hospital, Postboks 3250 Torgarden, 7006, Trondheim, Norway; Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NTNU, Faculty of Medicine and Health Sciences, N-7491 Trondheim, Norway
| |
Collapse
|
15
|
Xu F, Wheaton AG, Barbour KE, Liu Y, Greenlund KJ. Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017. Dig Dis Sci 2021; 66:1818-1828. [PMID: 32700169 PMCID: PMC10416557 DOI: 10.1007/s10620-020-06476-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/04/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes. AIMS We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017. METHODS We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples. RESULTS In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003). CONCLUSIONS Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.
Collapse
Affiliation(s)
- Fang Xu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
| | - Anne G Wheaton
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Kamil E Barbour
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Yong Liu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Kurt J Greenlund
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| |
Collapse
|
16
|
Chen YC, Chuang CH, Hsieh MH, Yeh HW, Yang SF, Lin CW, Yeh YT, Huang JY, Liao PL, Chan CH, Yeh CB. Risk of Mortality and Readmission among Patients with Pelvic Fracture and Urinary Tract Infection: A Population-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094868. [PMID: 34063602 PMCID: PMC8124968 DOI: 10.3390/ijerph18094868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/16/2022]
Abstract
Patients with pelvic fractures could encounter various complications during or after treatments. This cohort study investigated the risk of mortality and readmissions in patients with pelvic fractures, with or without urinary tract infections (UTIs), within 30 days following the pelvic fractures. This retrospective cohort study examined claim records from the Longitudinal Health Insurance Database 2000 (LHID2000). We selected patients hospitalized with pelvic fractures between 1997 and 2013 for study. Patients who had index data before 2000 or after 2010 (n = 963), who died before the index date (n = 64), who were aged <18 years (n = 94), or who had a pelvic injury (n = 31) were excluded. In total, the study cohort comprised 1623 adult patients; 115 had UTIs, and 1508 patients without UTIs were used as a comparison cohort. Multivariate analysis with a multiple Cox regression model and Kaplan-Meier survival analysis were performed to analyze the data. Our results showed that the 1-year mortality rate (adjusted hazard ratio [HR]: 2.32; 95% CI: 1.25-4.29) and readmission rate (adjusted HR: 1.72; 95% CI: 1.26-3.34) of the UTI group were significantly higher than those of the non-UTI group. Moreover, the Kaplan-Meier curve for the 1-year follow-up indicated that the UTI group had a higher cumulative risk of both mortality and hospital readmission compared with the non-UTI group. In conclusion, among patients with pelvic fracture, patients with UTI were associated with increased risks of mortality and readmission. Physicians must pay more attention to such patients to prevent UTIs among patients with pelvic fractures during hospitalization and conduct a follow-up after discharge within at least 1 year.
Collapse
Affiliation(s)
- Ying-Cheng Chen
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-C.C.); (C.-H.C.); (S.-F.Y.); (J.-Y.H.)
- Department of Surgery, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Cheng-Hsun Chuang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-C.C.); (C.-H.C.); (S.-F.Y.); (J.-Y.H.)
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Ming-Hong Hsieh
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Psychiatry, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Han-Wei Yeh
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-C.C.); (C.-H.C.); (S.-F.Y.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Chiao-Wen Lin
- Institute of Oral Sciences, Chung Shan Medical University, Taichung 402, Taiwan;
| | - Ying-Tung Yeh
- Graduate School of Dentistry, School of Dentistry, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Dentistry, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-C.C.); (C.-H.C.); (S.-F.Y.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Pei-Lun Liao
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
| | - Chi-Ho Chan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan;
- Department of Microbiology and Immunology, Chung Shan Medical University, Taichung 402, Taiwan
- Correspondence: (C.-H.C.); (C.-B.Y.)
| | - Chao-Bin Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (Y.-C.C.); (C.-H.C.); (S.-F.Y.); (J.-Y.H.)
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan;
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (C.-H.C.); (C.-B.Y.)
| |
Collapse
|
17
|
Prevalence of Swallowing and Eating Difficulties in an Elderly Postoperative Hip Fracture Population-A Multi-Center-Based Pilot Study. Geriatrics (Basel) 2020; 5:geriatrics5030052. [PMID: 32947876 PMCID: PMC7555319 DOI: 10.3390/geriatrics5030052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022] Open
Abstract
Elderly patients operated for hip fracture are characterized by high age and high degree of comorbidity and need of care, factors previously found to be associated with swallowing and eating difficulties. The aim of this study was to investigate the prevalence of swallowing and eating difficulties in an elderly postoperative hip fracture population and to identify factors associated with swallowing and eating difficulties. A cross-sectional multi-center pilot study was performed, including patients ≥65 years, operated for hip fracture, and able to participate in a swallowing and eating assessment. A clinical assessment was conducted using Danish versions of the standardized tools Volume-Viscosity Swallow Test and Minimal Eating Observation Form-version II. Demographic data and clinical characteristics were examined. A total of 78 patients (mean age 81.4 years (SD 7.8), 30.8% male) were included. Swallowing and eating difficulties were present in 60 patients (77%). Swallowing and eating difficulties were significantly associated with living in a nursing home before hospital admission (p = 0.014), low habitual New Mobility Score (p = 0.018), and absence of cardiac comorbidity (p = 0.023). The results underline the importance of focusing on swallowing and eating difficulties in elderly patients operated for hip fracture to ensure effectivity and safety and optimize the prognosis for the patient.
Collapse
|
18
|
Delgado A, Cordero G-G E, Marcos S, Cordero-Ampuero J. Influence of cognitive impairment on mortality, complications and functional outcome after hip fracture: Dementia as a risk factor for sepsis and urinary infection. Injury 2020; 51 Suppl 1:S19-S24. [PMID: 32067771 DOI: 10.1016/j.injury.2020.02.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/08/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the relation between cognitive impairment on arrival at hospital in patients older than 65 years with a hip fracture, and their mortality, medical and surgical complications, and functional outcomes. PATIENTS AND METHODS Observational study of a single-center prospective consecutive cohort of 955 patients older than 64 years diagnosed of hip fracture from December/2012 to December/2015. Average age was 86±7.2 (65-104) years and 725 (75.9%) were female. Fractures were extracapsular in 538 cases (56.3%) and intracapsular in 417 (43.7%). Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6, and 12 months. Data about basal cognitive status, walking ability before the fracture, medical and surgical complications, functional outcomes and mortality were collected for the year following the fracture. STATISTICAL ANALYSIS Bivariate analysis (Pearson, Fisher, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and contingence coefficients (CC) were calculated. RESULTS Patients with cognitive impairment showed a higher overall mortality, (p = 0,000; CC=0,197) even after hospital discharge (p = 0.000; CC=0.198). Similarly, patients with dementia presented a higher rate of respiratory infections (p = 0,029; CC=0,093), urinary tract infections (p = 0,008; CC=0,108) and sepsis (p = 0,011; CC=0,105). On the contrary, we found no correlations between mental status and surgical complications, even for prosthesis dislocation (p = 0.136). Patients with dementia started from poorer functional situations (p = 0,000; CC=0,367) and ended follow-up with lower walking ability (p = 0,000; CC=0,43), but cognitive impairment did not relate statistically with a worse functional recovery (p = 0,304): that is, the proportion of patients who maintained their previous ability to walk was similar in both groups, those with altered mental status and those without it. CONCLUSIONS Cognitive impairment is a risk factor for mortality in patients with a hip fracture. It is also a risk factor for suffering respiratory and urinary tract infection and sepsis. These two late risks factors have not been published previously. Functional recovery is not conditioned by cognitive impairment, although further studies need to be developed to evaluate the actual role of cognitive impairment on postoperative progression of patients.
Collapse
Affiliation(s)
- A Delgado
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, 28006 Madrid, Spain
| | - E Cordero G-G
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, 28006 Madrid, Spain
| | - S Marcos
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, 28006 Madrid, Spain
| | - J Cordero-Ampuero
- Department of Orthopaedic Surgery, University Hospital La Princesa, Universidad Autónoma de Madrid, 28006 Madrid, Spain.
| |
Collapse
|
19
|
Ouyang X, Ding Y, Yu L, Xin F, Yang X, Sha P, Tong S, Cheng Q, Xu YQ. Effects of hip replacement combined with alendronate sodium on postoperative healing of osteoporotic femoral neck fracture and levels of CTX-1 and BALP in patients. Exp Ther Med 2019; 18:4583-4590. [PMID: 31798698 PMCID: PMC6880394 DOI: 10.3892/etm.2019.8158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/02/2019] [Indexed: 12/21/2022] Open
Abstract
This study aimed to explore the improvement of hip replacement combined with alendronate sodium on the condition of patients with osteoporotic femoral neck fracture and factors affecting the efficacy of patients. In total, 140 patients with femoral neck fracture from July 2015 to October 2017 in the Affiliated Xuzhou Hospital of Jiangsu University were collected. Of these, 61 patients were treated with hip replacement as the control group and 79 patients were treated with alendronate sodium as the observation group on the basis of the control group. ELISA was used to detect levels of carboxy-terminal opeptide of type I collagen (CTX–I) and bone alkaline phosphatase (BALP) in serum of patients before and after treatment. Harris score was used to compare the clinical efficacy of patients after treatment. Changes in the expression of CTX–I and BALP before and after treatment were compared between the two groups, and the correlation between CTX–I and BALP levels and Harris score was analyzed. According to the clinical efficacy of patients, the two groups were divided into the significant effect group and poor effect group. Risk factors affecting the efficacy of patients were analyzed, and the ROC of subjects with risk factors was drawn. After treatment, the expression of BALP in serum increased significantly compared with that before treatment, and the expression of CTX–I decreased significantly. After treatment, the expression of BALP in serum in the observation group was significantly higher than that in the control group (P<0.05). Multivariate analysis revealed that age, time of operation, CTX–I after treatment and BALP after treatment were independent risk factors affecting the efficacy of patients. In conclusion, hip replacement combined with alendronate sodium can effectively improve the clinical efficacy of patients, and age, time of operation, CTX–I after treatment and BALP after treatment are found to be independent risk factors affecting the postoperative efficacy of patients.
Collapse
Affiliation(s)
- Xiao Ouyang
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Yunzhi Ding
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Li Yu
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Feng Xin
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Xiaowei Yang
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Peng Sha
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Songming Tong
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Qi Cheng
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| | - Yi Qi Xu
- Department of Orthopedic Surgery, Affiliated Xuzhou Hospital of Jiangsu University, Xuzhou Third Hospital, Xuzhou, Jiangsu 221005, P.R. China
| |
Collapse
|
20
|
Barbosa TDA, Souza AMFD, Leme FCO, Grassi LDV, Cintra FB, Lima RME, Gumieiro DN, Lima LHNE. [Perioperative complications and mortality in elderly patients following surgery for femoral fracture: prospective observational study]. Rev Bras Anestesiol 2019; 69:569-579. [PMID: 31722793 DOI: 10.1016/j.bjan.2019.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/30/2019] [Accepted: 09/09/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Perioperative management of femoral fractures in elderly patients has been studied to determine modifiable causes of complications and death. The aim of this study was to evaluate the mortality rate and its causes in the elderly population with FF. We also evaluated perioperative complications and their association with postoperative mortality. METHOD In this prospective and observational study, we evaluated 182 patients, by questionnaire and electronic medical record, from the moment of hospitalization to one year after surgery. Statistical analyzes using the multivariate Cox proportional hazards model and Kaplan-Meier curves were performed to detect independent mortality factors. RESULTS Fifty-six patients (30.8%) died within one year after surgery, and the main cause of death was infection followed by septic shock. The main complication, both preoperatively and postoperatively, was hydroelectrolytic disorder. For every one-unit (one-year) increase in age, the odds ratio for death increased by 4%. With each new preoperative complication, the odds ratio for death increased by 28%. Patients ASA III or IV had a 95% higher odds ratio for death than patiets ASA I or II. CONCLUSIONS Increasing age and number of preoperative complications, in addition to ASA classification III or IV, were independent factors of increased risk of death in the population studied. The mortality rate was 30.8%, and infection followed by septic shock was the leading cause of death.
Collapse
Affiliation(s)
- Talita de Almeida Barbosa
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Botucatu, SP, Brasil; Cooperativa dos Anestesiologistas de Ribeirão Preto, Ribeirão Preto, SP, Brasil.
| | | | | | | | | | - Rodrigo Moreira E Lima
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Serviço de Anestesiologia, Botucatu, SP, Brasil
| | - David Nicoletti Gumieiro
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil
| | - Lais Helena Navarro E Lima
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina, Departamento de Anestesiologia, Botucatu, SP, Brasil
| |
Collapse
|
21
|
Contro D, Elli S, Castaldi SI, Formili M, Ardoino I, Caserta AV, Panella L. Continuity of care for patients with hip fracture after discharge from rehabilitation facility. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:385-393. [PMID: 31580331 PMCID: PMC7233737 DOI: 10.23750/abm.v90i3.8872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 01/12/2023]
Abstract
Background and aims of the work: Hip fracture is a dramatic event especially in the elderly and the return to the pre-fracture functional and social state is often difficult to achieve. In the post-acute, the intensive rehabilitation period aims to recover as much autonomy as possible to these patients, but not always its duration is sufficient to ensure an effective and lasting result in returning home, hence the need for additional rehabilitation services. Our aim was to evaluate the use of additional rehabilitation services by patients who underwent hip fracture after an intensive rehabilitation treatment period performed at our hospital. Methods: This is a retrospective cohort study. We involved patients aged 45 years and older, admitted at our intensive rehabilitation, who joined a rehabilitation program for a hip fracture. Results: Our results showed how the use of further physiotherapy is associated with the type of surgical intervention and with higher Cumulative Illness Rating Scale CIRS scores. Similarly, the loss of autonomy is associated with the type of intervention, the increase in CIRS and the duration of the physiotherapy, and negatively associated with the duration of each session. The re-hospitalizations for each cause is positively associated with CIRS and negatively associated with the further use of physiotherapy. Conclusions: Our conclusion is that rehabilitation needs a personalized schedule, because the real discriminating factor in the management of frail patients should therefore be the quality, and not the quantity (i.e. longer session), of the rehabilitative intervention prescribed. (www.actabiomedica.it)
Collapse
Affiliation(s)
- Diego Contro
- School of Specialization in Physical and Rehabilitation Medicine, University of Milan.
| | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
A high proportion of patients with fragility fracture, mainly hip fracture, have a variable degree of comorbidity and show some degree of dependence in basic or more complex activities of daily living. Evaluating these patents following the geriatric concept of frailty, about one third of hip fracture patients may be categorised as frail with high risk of poor outcomes and prolonged length of stay, one third as not frail, and about one third with an intermediate condition. Due to the high vulnerability, combined with the hip fracture event and surgical repair procedures, a multidisciplinary approach that includes geriatric competencies becomes essential to improve short and long-term outcomes after hip fracture. A key element of an effective process of care is a true co-managed approach that applies quality standards and provides a fast-track pathway of care, minimises the time the patient spends in bed, and reduces postoperative complications by means of standardised procedures. The occurrence of a fragility fracture is the strongest risk factor for a subsequent fracture. Moreover, frail subjects have a further risk of fracture due to high risk of falls - related to loss of muscle mass, multiple illnesses, impaired balance and weakness. Thus, effective secondary prevention strategies are essential to reduce morbidity and mortality after hip fracture, and they are currently a standard task of orthogeriatric care. Fracture liaison services (FLS) are probably the most efficient way of addressing secondary prevention including the assessment of both bone health and falls risk. Therefore, the optimal management of frail patients with fragility fracture includes both orthogeriatric care and FLS, which are complementary to each other. Orthogeriatric collaboration is also powerful in influencing healthcare policy. British experience as well as that in Ireland, Australia and New Zealand, have shown that when two widely disparate specialisms say the same thing, they may achieve a fundamental shift in attitudes and behaviour of both managers and clinicians. Furthermore, a continuous real-time audit, at national level, is a powerful driver for change and better standards of care.
Collapse
|
23
|
Pre-discharge rehabilitation after hip surgery reduces 30-day readmissions in older adults: National Health Insurance Service–Senior Cohort (2007–2012). Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
24
|
Stone AV, Jinnah A, Wells BJ, Atkinson H, Miller AN, Futrell WM, Lenoir K, Emory CL. Nutritional markers may identify patients with greater risk of re-admission after geriatric hip fractures. INTERNATIONAL ORTHOPAEDICS 2017; 42:231-238. [PMID: 28988402 DOI: 10.1007/s00264-017-3663-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 09/24/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE Osteoporotic hip fractures are increasing in prevalence with the growing elderly population. Morbidity and mortality remain high following osteoporotic hip fractures despite advances in medical and surgical treatments. The associated costs and medical burdens are increased with a re-admission following hip fracture treatment. This study sought to identify demographic and clinical values that may be a predictive model for 30-day re-admission risk following operative management of an isolated hip fracture. METHODS Between January 1, 2013 and April 30, 2015 all patients admitted to a single academic medical centre for treatment of a hip fracture were reviewed. Candidate variables included standard demographics, common laboratory values, and markers of comorbid conditions and nutrition status. A 30-day, all-cause re-admission model was created utilizing multivariate logistic regression. RESULTS A total of 607 patients with hip fractures were identified and met the inclusion criteria; of those patients, 67 were re-admitted within 30 days. Univariate analysis indicates that the re-admission group had more comorbidities (p < 0.001) and lower albumin (p = 0.038) and prealbumin (p < 0.001). The final, reduced model contained 12 variables and incorporated four out of five nutritional makers with an internally, cross-validated C-statistic of 0.811 (95% CI: 0.754, 0.867). CONCLUSION Our results indicate that specific nutritional laboratory markers at the index admission may identify patients that have a greater risk of re-admission after hip fracture. This model identifies potentially modifiable risk factors and may allow orthogeriatricians to better educate patients and better treat post-operative nutritional status and care.
Collapse
Affiliation(s)
- Austin V Stone
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alexander Jinnah
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
| | - Brian J Wells
- Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Family Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Public Health Sciences, Wake Forest University Graduate School of Arts and Sciences, Winston-Salem, NC, USA
| | - Hal Atkinson
- Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Anna N Miller
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Wendell M Futrell
- Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kristin Lenoir
- Translational Science Institute, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Cynthia L Emory
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA
| |
Collapse
|
25
|
Ali AM, Gibbons CER. Predictors of 30-day hospital readmission after hip fracture: a systematic review. Injury 2017; 48:243-252. [PMID: 28063674 DOI: 10.1016/j.injury.2017.01.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/26/2016] [Accepted: 01/01/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Early readmission to hospital after hip fracture is associated with increased mortality and significant costs to the healthcare system. There is growing interest in the use of 30-day readmission rates as a metric of hospital performance. Identifying patients at increased risk of readmission after hip fracture may enable pre-emptive action to mitigate this risk and the development of effective methods of risk-adjustment to allow readmission to be used as a reliable measure of hospital performance. METHODS We conducted a systematic review of bibliographic databases and reference lists up to July 2016 to identify primary research papers assessing the effect of patient- and hospital-related risk factors for 30-day readmission to hospital after hip fracture. RESULTS 495 papers were found through electronic and reference search. 65 full papers were assessed for eligibility. 22 met inclusion criteria and were included in the final review. Medical causes of readmission were significantly more common than surgical causes, with pneumonia consistently being cited as the most common readmission diagnosis. Age, pre-existing pulmonary disease and neurological disorders were strong independent predictors of readmission. ASA grade and functional status were more robust predictors of readmission than the Charlson score or individual co-morbidities. Hospital-related risk factors including initial length of stay, hospital size and volume, time to surgery and type of anaesthesia did not have a consistent effect on readmission risk. Discharge location and the strength of hospital-discharge facility linkage were important determinants of risk. CONCLUSIONS Patient-related risk factors such as age, co-morbidities and functional status are stronger predictors of 30-day readmission risk after hip fracture than hospital-related factors. Rates of 30-day readmission may not be a valid reflection of hospital performance unless a clear distinction can be made between modifiable and non-modifiable risk factors. We identify a number of deficiencies in the existing literature and highlight key areas for future research.
Collapse
Affiliation(s)
- Adam M Ali
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
| | | |
Collapse
|
26
|
Abstract
PURPOSE Analysis of significant risk factors for mortality and for medical and orthopaedic complications. PATIENTS AND METHODS Observational study of a prospective consecutive cohort of 697 patients diagnosed of hip fracture from December 2012 to December 2014. Average age was 85±9years and 520 were female (75%). Intracapsular fractures (308, 44%) were treated non-operatively, (19 patients), with cannulated screws (58) or with hip arthroplasty (228 bipolar, 3 total hip atrhoplasty). Extracapsular fractures (389, 56%) were reduced and fixed with 375 trochanteric nails and 14 sliding-hip-screw-plates. Patients were controlled clinically and radiographically in outpatient clinic after 1, 3, 6 and 12months. Bivariate analysis (Pearson, Mann-Whitney, Wilcoxon) was applied to study statistically significant relations, and Odds Ratio were calculated. RESULTS Surgical delay reached 2.1±2.2days, 1.7±1.9 in medically stable patients. Main reason for delay was anticoagulant/anti-platelet therapy. Immediate weight-bearing was begun for 72% of patients. Average time in-hospital was 12±8days and 63% returned to previous environment. Lost-to-follow-up reached 4% after 1month and 8% after 6months. After 1year, 6% of previously-walking patients were unable to walk. Mortality reached 4% while in-hospital and 14% after 1year, with older age as only significant risk factor (p=0.004), OR=1.9. Wound infection developed in 2.3% of the series, and surgical delay longer than 24hours was a significant risk factor (p=0.023), with an OR=3.48 (1.1-10.8). Fixation failed in 7.9% of cannulated screws and 1.9% of trochanteric nails (1.1% cut-out, 0.8% nail fracture), while 2.7% of arthroplasty patients suffered a prosthesis dislocation and 1.3% a periprosthetic fracture. Pyelonephritis appeared in 6.7%, pneumonia in 6.3% and cardiac failure in 2.2% of patients; significant risk factors were previous comorbidity for pneumonia (p=0.007) (OR=2.7) and cardiac failure (p=0.007) (OR=9.7), as well as older age (p=0.006) (OR=2.2) for pneumonia. CONCLUSIONS Surgical delay longer than 24hours has been an important risk factor for wound infection, a finding not previously described in literature. Older age is a significant risk factor for mortality and pneumonia, and previous comorbidity for cardiac failure and pneumonia.
Collapse
Affiliation(s)
- José Cordero
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Alfonso Maldonado
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sergio Iborra
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| |
Collapse
|
27
|
Dong C, Wang Y, Wang Z, Wang Y, Wu S, Du Q, Wang A. Damage Control Orthopedics Management as Vital Procedure in Elderly Patients with Femoral Neck Fractures Complicated with Chronic Renal Failure: A Retrospective Cohort Study. PLoS One 2016; 11:e0154906. [PMID: 27149117 PMCID: PMC4858305 DOI: 10.1371/journal.pone.0154906] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 04/20/2016] [Indexed: 11/30/2022] Open
Abstract
Background Chronic renal failure (CRF) predisposes to hip fractures in elderly patients, with high subsequent mortality. Selection and timing of the surgical procedure of such patients is a serious challenge. Many clinicians believe in earlier surgery as preferable and providing better outcomes. Damage control orthopedics (DCO) aids to adjust and optimize the overall condition of patients. Methods In 32 patients with femoral neck fractures complicated with CRF, we evaluated how the timing of the surgery determines the mortality rates if the DCO approach is applied. Preoperative ASA grading, POSSUM score, P-POSSUM score and DCO were carried out. Based on the assessment, timing of the surgery was ascertained. Results Of a total of 32 patients, twenty-nine patients were accepted for either early (< 48 hours; n = 18) or delayed (3–10 days; n = 10) surgery. Hip arthroplasty (total hip arthroplasty and hemiarthroplasty) was the principal surgery option. All patients survived operation and were followed up postoperatively with the average time of 30 days. Postoperative complications tended to occur at higher rates in the early vs. delayed surgery group (7/18 vs. 5/10). During follow up, a total of 3 patients died in both groups (2/18 in the early surgery and 1/10 in the delayed surgery group), mostly from multi-organ failures and acute respiratory distress syndrome. There was no significant difference in complication rates and Harris hip score between both groups. Conclusion In patients with femoral neck fracture complicated with CRF, delaying the surgery for several days does not increase the incidence of postoperative adverse events.
Collapse
Affiliation(s)
- Chenhui Dong
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Yunjiao Wang
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Ziming Wang
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Yu Wang
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Siyu Wu
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Quanyin Du
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Aimin Wang
- Department of Orthopedics, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
- * E-mail:
| |
Collapse
|