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Ikram A, Norrish A, Ollivere L, Nightingale J, Valdes A, Ollivere BJ. Has a change in established care pathways during the first wave of the COVID-19 pandemic led to an excess death rate in the fragility fracture population? A longitudinal cohort study of 1846 patients. BMJ Open 2022; 12:e058526. [PMID: 35523492 PMCID: PMC9082727 DOI: 10.1136/bmjopen-2021-058526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/31/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE During the first wave of the COVID-19 pandemic, changes to established care pathways and discharge thresholds for patients with fragility fractures were made. This was to increase hospital bed capacity and minimise the inpatient risk of contracting COVID-19. This study aims to identify the excess death rate in this population during the first wave of the pandemic. DESIGN A longitudinal cohort study of patients with fragility fractures identified by specific International Classification of Diseases (ICD)-10 codes. The first wave of the pandemic was defined as the 3-month period between 1 March and 1 June 2020. The control group presented between 1 March and 1 June 2019. SETTING Two acute National Health Service hospitals within the East Midlands region of England. PARTICIPANTS 1846 patients with fragility fractures over the aforementioned two specified matched time points. PRIMARY AND SECONDARY OUTCOME MEASURES Four-month mortality of all patients with fragility fractures with a subanalysis of patients with fragility hip fractures. RESULTS 832 patients with fragility fracture were admitted during the pandemic period (104 diagnosed with COVID-19). 1014 patients presented with fragility fractures in the control group. Mortality in patients with fragility fracture without COVID-19 was significantly higher among pandemic period admissions (14.7%) than the pre-pandemic cohort (10.2%) (HR=1.86; 95% CI 1.41 to 2.45; p<0.001) adjusted for age and sex. Length of stay was shorter during the pandemic period (effect size=-4.2 days; 95% CI -5.8 to -3.1, p<0.001). Subanalysis of patients with fragility hip fracture revealed a mortality of 8.4% in the pre-pandemic cohort, and 15.48% during pandemic admissions with no COVID-19 diagnosis (HR=2.08; 95% CI 1.11 to 3.90; p=0.021). CONCLUSIONS There is a significant increase in excess death, not explained by confirmed COVID-19 infections. Altered care pathways and aggressive discharge criteria during the pandemic are likely responsible for the increase in excess deaths.
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Affiliation(s)
- Adeel Ikram
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham School of Medicine, Nottingham, UK
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Norrish
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham School of Medicine, Nottingham, UK
- Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Luke Ollivere
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jessica Nightingale
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham School of Medicine, Nottingham, UK
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ana Valdes
- School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Benjamin J Ollivere
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham School of Medicine, Nottingham, UK
- Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
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Díez-Manglano J, Berges Vidal M, Martínez Barredo L, Poblador-Plou B, Gimeno-Miguel A, Martínez Heras P, Prados-Torres A. Chronic Obstructive Pulmonary Disease and Incidence of Hip Fracture: A Nested Case-Control Study in the EpiChron Cohort. Int J Chron Obstruct Pulmon Dis 2020; 15:2799-2806. [PMID: 33177817 PMCID: PMC7652231 DOI: 10.2147/copd.s270713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine whether chronic obstructive pulmonary disease (COPD) is a risk factor for hip fracture and identify other factors associated with hip fracture. Patients and Methods Observational nested case-control study was conducted in Aragon, Spain in 2010. We included COPD patients aged >40 years, in the EpiChron cohort. Each COPD patient was matched for age, sex, and number of comorbidities with a control subject without COPD. Patients with an existing diagnosis of osteoporosis and those with hip fracture before 2011 were excluded. We collected baseline demographic, comorbidity, and pharmacological treatment data. During a 5-year follow-up period, we recorded the incidence of hip fracture. A logistic regression model was constructed to identify factors associated with hip fracture. Results The study population consisted of 26,517 COPD patients and the same number of controls (median [interquartile range] age, 74 [17] years; women, 24.7%). Smoking and heart failure were more frequent in COPD patients, and obesity, hypertension, diabetes, dyslipidemia, stroke, arthritis, and visual or hearing impairment were less frequent (all p<0.001). Consumption of benzodiazepines (p=0.037), bronchodilators (p<0.001), and corticosteroids (p<0.001) was higher in the COPD group, while that of beta-blockers and thiazides was lower (both p<0.001). During follow-up, 898 (1.7%) patients experienced hip fracture, with no differences observed between COPD and control patients. Multivariate analysis revealed that independent of COPD status, age, female sex, chronic liver disease, heart failure, and benzodiazepine use were independently associated with a higher risk of hip fracture, and obesity with a lower risk. In COPD patients, use of inhaled anticholinergics was independently associated with hip fracture (OR, 1.390; 95% CI 1.134-1.702; p=0.001). Conclusion COPD is not a risk factor for a hip fracture within 5 years. The association between the use of inhaled anticholinergics and risk of hip fracture warrants further study.
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Affiliation(s)
- Jesús Díez-Manglano
- Internal Medicine Department, Royo Villanova Hospital, Zaragoza, Spain.,EpiChron Research Group, Aragon Health Sciences Institute, IIS Aragón, REDISSEC, Zaragoza, Spain
| | - María Berges Vidal
- EpiChron Research Group, Aragon Health Sciences Institute, IIS Aragón, REDISSEC, Zaragoza, Spain
| | | | - Beatriz Poblador-Plou
- EpiChron Research Group, Aragon Health Sciences Institute, IIS Aragón, REDISSEC, Zaragoza, Spain
| | - Antonio Gimeno-Miguel
- EpiChron Research Group, Aragon Health Sciences Institute, IIS Aragón, REDISSEC, Zaragoza, Spain
| | - Pilar Martínez Heras
- Internal Medicine Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Alexandra Prados-Torres
- EpiChron Research Group, Aragon Health Sciences Institute, IIS Aragón, REDISSEC, Zaragoza, Spain
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Gupta A, Jayes LR, Holmes S, Sahota O, Canavan M, Elkin SL, Lim K, Murphy AC, Singh S, Towlson EA, Ward H, Scullion J, McKeever TM, Bolton CE. Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement. Int J Chron Obstruct Pulmon Dis 2020; 15:1377-1390. [PMID: 32606647 PMCID: PMC7311204 DOI: 10.2147/copd.s233398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD. Methods A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like. Results The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required. Conclusion There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required.
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Affiliation(s)
- Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Leah R Jayes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Steve Holmes
- General Practitioner, Park Medical Partnership, Shepton Mallet, UK
| | - Opinder Sahota
- Department of Geriatric Medicine, Nottingham University Hospitals Trust, Nottingham, UK
| | - Melissa Canavan
- Department of Respiratory, Respiratory Care Solutions, Leeds, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London W2 1NY, UK; Airways Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Kelvin Lim
- Eastwood Primary Care Centre, Eastwood, Nottingham, UK
| | - Anna C Murphy
- Department of Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Singh
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Science, University of Leicester, Leicester, UK
| | | | - Helen Ward
- Faculty of Medicine, The Royal Wolverhampton NHS Trust, West Midlands, UK
| | - Jane Scullion
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
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Morgan L, McKeever TM, Nightingale J, Deakin DE, Moppett IK. Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching. Anaesthesia 2020; 75:1173-1179. [PMID: 32337715 DOI: 10.1111/anae.15042] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2020] [Indexed: 11/30/2022]
Abstract
Around 76,000 people fracture their hip annually in the UK at a considerable personal, social and financial cost. Despite longstanding debate, the optimal mode of anaesthesia (general or spinal) remains unclear. Our aim was to assess whether there is a significant difference in mortality and morbidity between patients undergoing spinal anaesthesia compared with general anaesthesia during hip fracture surgery. A secondary analysis examined whether a difference exists in mortality for patients with pre-existing cardiovascular disease or chronic obstructive pulmonary disease. This was a clinical database analysis of patients treated for hip fracture in Nottingham, UK between 2004 and 2015. Propensity score-matching was used to generate matched pairs of patients, one of whom underwent each mode of anaesthesia. Data were analysed using conditional logistic regression, with 7164 patients successfully matched. There was no difference in 30- or 90-day mortality in patients who had spinal rather than general anaesthesia (OR [95%CI] 0.97 [0.8-1.15]; p = 0.764 and 0.93 [0.82-1.05]; p = 0.247 respectively). Patients who had a spinal anaesthetic had a lower-risk of blood transfusion (OR [95%CI] 0.84 [0.75-0.94]; p = 0.003) and urinary tract infection (OR [95%CI] 0.72 [0.61-0.84]; p < 0.001), but were more likely to develop a chest infection (OR [95%CI] 1.23 [1.07-1.42]; p = 0.004), deep vein thrombosis (OR [95%CI] 2.18 [1.07-4.45]; p = 0.032) or pulmonary embolism (OR [95%CI] 2.23 [1.16-4.29]; p = 0.016). The mode of anaesthesia for hip fracture surgery resulted in no significant difference in mortality, but there was a significant difference in several measures of postoperative morbidity.
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Affiliation(s)
- L Morgan
- Division of Epidemiology and Public Health, University of Nottingham, UK
| | - T M McKeever
- Division of Epidemiology and Public Health, University of Nottingham, UK
| | - J Nightingale
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D E Deakin
- Department of Trauma and Orthopaedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - I K Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK
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