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

Trends in Incidence of Hip Fracture and Hip Replacement in Denmark, 1996 to 2018

Importance

The past several decades have witnessed substantial changes in treatments that are particularly relevant for older patients.

Objectives

To assess changes in national-level incidence rates of fracture- and musculoskeletal-related (ie, arthritis-related) hip replacement procedures for individuals aged 40 to 104 years over a 23-year period in Denmark.

Design, Setting, and Participants

This cohort study used national Danish health registers to include the Danish population aged 40 to 104 years from January 1, 1996, to December 31, 2018. Data were analyzed from May 31, 2022, to February 14, 2024.

Main Outcomes and Measures

Age- and period-specific incidence rates of hip fracture and hip replacement stratified on fracture-related vs arthritis-related indication.

Results

From 1996 to 2018, a total of 3 664 979 individuals were followed up for a mean (SD) of 14.6 (7.7) years, resulting in a follow-up time of 53 517 861 person-years and 158 982 (first) hip fractures, of which 42 825 involved fracture-related hip replacement procedures. A further 104 422 individuals underwent arthritis-related hip replacement. During the first 2 decades of the 21st century, hip fracture rates declined by 35% to 40% for individuals aged 70 to 104 years, and the proportion of the population undergoing fracture-related hip replacement increased by 50% to 70%, with modest variation across those aged 75 to 99 years. Rates of arthritis-related hip replacements peaked for individuals aged 75 to 79 years, but with the largest relative rate increase (75%-100%) occurring for those aged 80 to 94 years, primarily from 2001 to 2015, whereafter it remained nearly unchanged. The decline in rates of arthritis-related hip replacement after 75 to 79 years of age was gradual and did not suggest an upper age limit for access to arthritis-related hip replacement.

Conclusions and Relevance

The findings of this cohort study suggest that during the past several decades in Denmark, the incidence of hip fractures declined by 35% to 40% among patients aged 80 to 104 years, while the proportion receiving fracture-related hip replacement remained relatively constant after 75 years of age. During the first decades of the 21st century, arthritis-related hip replacement incidence increased by 50% to 100% among older patients and stabilized hereafter, with no apparent cutoff age for this type of procedure. These patterns indicate a positive overall trend with declining hip fracture incidence over the last decades in Denmark, and the observed hip replacement incidence suggests that age is currently not a major determining factor guiding this type of surgery.

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.

Hip fractures after 60 years of age in France in 2005-2017: Nationwide sample of statutory-health-insurance beneficiaries

BACKGROUND

Proximal femoral factures (PFFs) constitute a heavy medical, social, and economic burden. Overall, orthopaedic conditions vary widely in France regarding the patients involved and treatments applied. For PFFs specifically, data are limited. Moreover, the ongoing expansion of geriatric orthopaedics holds promise for improving overall postoperative survival. The objectives of this retrospective study of a nationwide French database were: 1) to describe the pathway of patients with PFFs regarding access to care, healthcare institutions involved, and times to management; 2) to look for associations linking these parameters to post-operative mortality.

HYPOTHESIS

Across France, variations exist in healthcare service availability and time to management for patients with PFFs.

MATERIAL AND METHODS

A retrospective analysis of data in a de-identified representative sample of statutory-health-insurance beneficiaries in France (Échantillon généraliste des bénéficiaires, EGB, containing data for 1/97 beneficiaries) was conducted. All patients older than 60 years of age who were managed for PFFs between 2005 and 2017 were included. The following data were collected for each patient: age, management method, Charlson's Comorbidity Index (CCI), home-to-hospital distance by road, and type of hospital (public, non-profit private, or for-profit private), and time to surgery were collected. The study outcomes were the incidence of PFF, mortality during the first postoperative year, changes in mortality between 2005 and 2017, and prognostic factors.

RESULTS

In total 8026 fractures were included. The 7561 patients had a median age of 83.8 years and a mean CCI of 4.6; both parameters increased steadily over time, by 0.18 years and 0.06 points per year, respectively (p<10-4 for both comparisons). Management was by total hip replacement in 3299 cases and internal fixation in 4262 cases; this information was not available for 465 fractures. The overall incidence increased from 90/100,000 in 2008 to 116/100,000 in 2017 (p=0.03). Of the 8026 fractures, 5865 (73.1%) were managed in public hospitals (and this proportion increased significantly over time), 1629 (20.3%) in non-profit private hospitals (decrease over time), and 264 (3.3%) in for-profit private hospitals. The home-to-hospital distance ranged from 7.5 to 38.5km and increased over time by 0.26km/year (95% confidence interval [95%CI]: 0.15-0.38) (p<10-4). Median time to surgery was 1 day [1-3 days], with no significant difference across hospital types. Mortality rates at 90 days and 1 year were 10.5% (843/8026) and 20.8% (1673/8026), respectively. Two factors were significantly associated with day-90 mortality: the CCI (hazard ratio [HR], 1.087 [95%CI: 1.07-1.10] [p<10-4]) and time to surgery>1 day (HR 1.35 [95%CI: 1.15-1.50] [p<0.0001]). Day-90 mortality decreased significantly from 2005 to 2017 (HR 0.95 [95%CI: 0.92-0.97] [p<10-4]), with no centre effect.

CONCLUSION

The management of PFF in patients older than 60 varied widely across France. Time to surgery longer than 1 day was a major adverse prognostic factor whose effects persisted throughout the first year. This factor was present in over half the patients. Day-90 mortality decreased significantly from 2005 to 2017 despite increases in age and comorbidities.

LEVEL OF EVIDENCE

IV Retrospective cohort study.