Factors associated to institutionalization and mortality over three years, in elderly people with a hip fracture—An observational study

Comorbidity burden and nutritional status are associated with short-term improvement in functional independence and pain intensity after hip fracture surgery in older adults with in-hospital rehabilitation

PURPOSE

Hip fracture is a common condition among older adults. The aim of this study was to explore the influence of nutritional status and comorbidity burden on changes in functionality, fall risk, and pain intensity one month after hip surgery in older adults with in-hospital rehabilitation.

METHODS

Thirty-six hip fracture patients (55.6% female) aged 65 years or older with indication for surgical resolution were recruited. The main outcomes were functional independence (Barthel Index), risk of falls (Downton Falls Risk Index) and pain intensity (Visual Analogue Scale), assessed preoperatively and one month after discharge. Covariates included age, sex, BMI, Charlson Comorbidity Index (CCI) and nutritional status (Mini Nutritional Assessment). For the inferential analysis, a one-way analysis of covariance (ANCOVA) was applied.

RESULTS

Significant improvements were observed in functional independence (11.0 points, 95% CI: 1.7 to 20.3), risk of falls (-2.8 points, 95% CI: -4.0 to -1.7) and pain intensity (-2.6 points, 95% CI: -3.4 to -1.9). Among the covariates, a significant interaction was found between the CCI and improvements in functional independence (F=7.03, p=0.010, η2p=0.093), while nutritional status showed a significant interaction with pain reduction (F=5.65, p=0.020, η2p=0.075).

CONCLUSION

A lower comorbidity burden was associated with greater postoperative functional independence, while better nutritional status was associated with a greater reduction in postoperative pain intensity.

A 10-Year Experience of an Integrated Geriatric Hip Fracture Treatment Protocol: Outcomes at a Minimum 2-Year Follow-Up

Introduction

Increasing incidence of fragility fractures has spurred development of protocols, largely focused on peri-operative care, with numerous proven benefits. The purpose of this investigation was to evaluate outcomes of our hip fracture treatment program regarding successful protocol implementation, compliance, effect on subsequent fracture rates, and mortality during the first decade of adoption.

Methods

A retrospective review identified patients >65 years old with fragility hip fractures between 2010 and 2022. The HiROC (+) cohort consisted of patients who received a "High-Risk Osteoporosis Clinic" (HiROC) referral for bone health evaluation and bisphosphonate initiation as indicated. Additional fracture rates and mortality at 3 years were calculated. Protocol implementation and compliance over the first 10 years was analyzed in the four identified cohorts.

Results

A total of 1671 fragility hip fractures were identified, with 386 excluded due to insufficient follow-up, with an average age of 81.6 years and a median follow-up of 36.4 months. Of the 1280 included cases, 56% (n = 717) had a HiROC referral placed. HiROC(+) groups had lower subsequent fracture rates at two years, compared to those without referral (28% vs 13%, P < 0.0001) and those completing more steps of the protocol had lower subsequent fracture rates (28% vs 15% vs 13% vs 5%, P < 0.0001). No statistically significant difference was observed between the cohorts for anatomic site of subsequent fractures.

Discussion

Greater than half of all eligible patients were successfully captured by the protocol. Patients completing more steps of the protocol had lower subsequent fracture rates. Captured patients demonstrated reduced mortality rates when compared to current literature.

Conclusion

Successful implementation of this geriatric hip fracture protocol was associated with reduced additional fractures and mortality rates. Identifying steps of process failures in the protocol can provide opportunities for increased compliance and reduction in future fracture occurrences.

Association between institutionalization by 4 months post-discharge walking capacity and lean body mass in elderly hip fracture patients: Evidence from a Swedish Registry Based Study

Background and purpose

Losing independence is a main concern for hip fracture patients, and particularly not being able to return home. Given the large impact on quality of life by loss of independence and the high risk for institutionalization after hip fracture, it is of importance to identify modifiable risk factors for such negative outcomes. This study aimed to investigate the association between two such factors, that is, lean body mass and 4 months post-discharge walking capacity, and the risk of institutionalization in previously independent living older people who suffer a hip fracture.

Patients and methods

A retrospective cohort study was conducted using Swedish national-based population registers. Patients ⩾60 years with a hip fracture during 2008-2017 were included from the Swedish National Registry for Hip Fractures. Risk of institutionalization over the 1-year period following a hip fracture was analyzed using logistic regression analyses adjusted for potential predictors and characteristics.

Results

In total, 11,265 patients were included. Over the first year, 8% (95% CI: 8-9) of the patients with a hip fracture had lost independence, increasing to 15% (95% CI: 14-16) after 5 years. Poor recovery of post-discharge walking ability was associated with a higher odds ratio of losing independence compared with good recovery (OR 12.0; 95% CI: 7.8-18.4; p < 0.001). Having higher estimated lean body mass than 45 kg at index was associated with lower odds of losing independence.

Conclusion

Maintaining lean body mass and mobility after a hip fracture is likely important from an individual as well as public health perspective.

Bone turnover biomarkers predict one-year all-cause mortality and walking ability in geriatric hip fracture patients

PURPOSE

To investigate the utility of serum C-terminal cross-linking telopeptides (β-CTX) and procollagen type I N propeptide (PINP) for predicting one-year mortality and walking ability in Chinese geriatric hip fracture patients who underwent surgical interventions.

METHOD

Elderly patients (≥ 60 years) who underwent surgical interventions for unilateral low-energy hip fracture from 2015 to 2020 in our center were included. Demographic data was retrospectively retrieved from the electronic medical database. The PINP and β-CTX concentrations were measured before the surgery. The patients were divided into two groups according to the outcome of mortality and walking ability after hip surgery, respectively. β-CTX and PINP were divided into four grades based on quartiles [Quartile(Q)1-4] for further analysis. All the variables with p < 0.1 in univariable analysis were included in a multivariable model.

RESULTS

In univariable analysis, the levels of serum β-CTX (p = 0.007) and PINP (p = 0.025) was associated with one-year mortality, while the association between levels of serum β-CTX (p = 0.072) or PINP (p = 0.055) with one-year disability was marginally significant. After adjustment for confounders, the relative risk [OR (95 % CI), Q4 v sQ1, p-value] of one-year mortality and one-year disability were 7.28 (2.08-29.78, p = 0.003) and 3.97 (1.44-11.69, p = 0.009) for β-CTX and 5.87 (1.70-23.80, p = 0.008) and 3.48 (1.30-9.93, p = 0.016) for PINP, respectively. The coefficient of determination, AUC and bias-corrected C-index of predictive models based on previously reported predictors were significantly improved after integrating β-CTX or PINP.

CONCLUSION

Higher serum β-CTX and PINP are independently associated with an increased risk of one-year mortality and disability in patients with hip fractures. The application of BTMs improves the performance of currently available predictive models.

[Functional recovery units state in orthogeriatrics according to data from the National Registry of Hip Fracture]

INTRODUCTION

The National Registry of Hip Fractures (RNFC) facilitates knowledge of hip fracture process in Spain to clinicians and managers and is useful to the reduction of the results variability, including the destination at discharge after the hip fracture.

OBJECTIVE

The aim of this study was to describe functional recovery units (URFs) use for patients with hip fracture included in the RNFC and to compare the results of the different autonomous communities (AC).

MATERIAL AND METHODS

An observational, prospective and multicenter study of several hospitals in Spain. Data from a RNFC cohort of patients admitted with hip fracture between 2017 and 2022 were analyzed, focusing on the location at discharge of the patients, specifically on transfer to the URF.

RESULTS

52,215 patients from 105 hospitals were analyzed, 9540 patients (18.1%) were transferred to URF upon discharge and 4595 (8.8%) remained in these units 30 days later, with a variable distribution between the different AC (0-49%) and variability of results in patients not recovering ambulation at 30 days (12.2-41.9%).

CONCLUSIONS

There is in orthogeriatric patient an unequal availability and use of URFs between different autonomous communities. The study of the usefulness of this resource can be of great value for decision-making in health policies.

Predictors of Nursing Home Entry within 36 Months after Hospitalization via the Emergency Department among Persons Aged 75 Years or Older

OBJECTIVE

We aimed to identify risk factors for nursing home (NH) entry 36 months after hospitalization via the emergency department (ED) in a population of patients aged 75 years or older.

METHODS

This was a prospective multicentre cohort. Patients were recruited from the emergency departments (EDs) of nine hospitals. Subjects had been hospitalised in a medical ward in the same hospital as the ED to which they were initially admitted. Subjects who experienced NH entry prior to ED admission were excluded. NH entry has been defined as the incident admission either into an NH or other long-term care facility within the follow-up period. Variables from a comprehensive geriatric assessment of patients were entered into a Cox model with competing risks to predict NH entry during 3 years of follow-up.

RESULTS

Among 1306 patients included in the SAFES cohort, 218 (16.7%) who were already in an NH were excluded. The remaining 1088 patients included in the analysis were aged 84 ± 6 years on average. During 3 years of follow-up, 340 (31.3%) entered an NH. The independent risk factors for NH entry were that they: living alone (Hazard ratio (HR) 2.00, had a 95% confidence interval (CI) 1.59-2.54, p < 0.0001), could not independently perform activities of daily living (HR 1.81, 95% CI 1.24-2.64, p = 0.002), and had balance disorders (HR 1.37, 95% CI 1.09-1.73, p = 0.007), dementia syndrome (HR 1.80, 95% CI 1.42-2.29, p < 0.0001) and a risk of pressure ulcers (HR 1.42, 95% CI 1.10-1.82, p = 0.006).

CONCLUSION

The majority of the risk factors for NH entry within 3 years after emergency hospitalization are amenable to intervention strategies. It is therefore reasonable to imagine that targeting these features of frailty could delay or prevent NH entry and improve the quality of life of these individuals before and after NH entry.

Hospital In Home: Evaluating Need and Readiness for Implementation (HENRI) in the Department of Veterans Affairs: protocol for a mixed-methods evaluation and participatory implementation planning study

Background and objectives

The Department of Veterans Affairs (VA) Hospital-In-Home (HIH) program delivers patient-centered, acute-level hospital care at home. Compared to inpatient care, HIH has demonstrated improved patient safety, effectiveness, and patient and caregiver satisfaction. The VA Office of Geriatrics & Extended Care (GEC) has supported the development of 12 HIH program sites nationally, yet adoption in VA remains modest, and questions remain regarding optimal implementation practices to extend reach and adaptability of this innovation. Guided by theoretical and procedural implementation science frameworks, this study aims to systematically gather evidence from the 12 HIH programs and to develop a participatory approach to engage stakeholders, assess readiness, and develop/adapt implementation strategies and evaluation metrics.

Research design and methods

We propose a multi-phase concurrent triangulation design comprising of (1) qualitative interviews with key informants and document review, (2) quantitative evaluation of effectiveness outcomes, and (3) mixed-methods synthesis and adaptation of a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM)-guided conceptual framework.

Results

The prospective phase will involve a participatory process of identifying stakeholders (leadership, HIH staff, veterans, and caregivers), engaging in planning meetings informed by implementation mapping, and developing implementation logic models and blueprints. The process will be assessed using a mixed-methods approach through participant observation and document review.

Discussion and implication

This study will support the continued spread of HIH programs, generate a catalog of HIH implementation evidence, and create implementation tools and infrastructure for future HIH development. The multi-phase nature of informing prospective planning with retrospective analysis is consistent with the Learning Health System framework.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00338-7.

Post-fracture rehabilitation pathways and association with mortality among adults with cerebral palsy

OBJECTIVE

Rehabilitation may mitigate the high mortality rates and health declines post-fracture for adults with cerebral palsy, but this is understudied. The objectives were to characterize the post-fracture rehabilitation pathways and identify their association with 1-year survival among adults with cerebral palsy.

METHODS

A retrospective cohort study of adults with cerebral palsy with a fragility fracture with continuous health plan enrollment ≥1-year prior to and ≥1 day after their fracture date was performed using a random 20% Medicare fee-for-service dataset. Participants were categorized as a home discharge or inpatient rehabilitation admission post-fracture. For the home discharge cohort, weekly exposure to outpatient physical/occupational therapy (PT/OT) was examined up to 6-month post-fracture. Cox regression examined the association between time-varying PT/OTuse within 6-month post-fracture and mortality from 30 days to 1-year post-fracture before and after adjusting for confounders (e.g. medical complexity).

RESULTS

Of 3598 adults with cerebral palsy with an incident fragility fracture, 74% were discharged home without inpatient rehabilitation; they were younger, but more medically complex compared to the 26% admitted to inpatient rehabilitation. Among the home discharge cohort (n = 2662), 43.1% initiated PT/OTwithin 6-month post-fracture, and cumulative PT/OTexposure post-fracture was associated with improved survival; for example, per 3 weeks of PT/OTexposure, the adjusted mortality rate was 40% lower (95% confidence interval (CI) = 0.41-0.89).

CONCLUSIONS

Most adults with cerebral palsy with a fragility fracture were discharged home rather than to inpatient rehabilitation, and only 43.1% of that group initiated outpatient PT/OTwithin 6 months post-fracture. Receiving outpatient PT/OTwas associated with improved 1-year survival.

Dizziness is a predictor factor for the risk of falls in institutionalised older adults in Brazil

Considering the small number of studies aimed at evaluating outcomes related to dizziness and falls in the older adults who live in long-term care facilities, especially in north-eastern Brazil, and considering the negative impact of these events on the quality of life of these individuals, this study purpose was to evaluate dizziness as a predictor of risk of falls in institutionalised older adults. This cross-sectional analysis of data on falls and dizziness of 187 institutionalised older adults carried out between the years 2014 and 2016. The data collection instruments used were a socioeconomic and demographic questionnaire and questionnaires for assessing variables related to falls. The different diagnostic methods were compared using the Spearman correlation, and the Dizziness variable was evaluated by means of logistic regression. Inferential statistical analysis showed a significant association between dizziness and number of morbidities (p = .03) and dizziness and a history of falls (p = .04). Spearman's correlation analysis revealed statistically significant results only for FES-I (Falls Efficacy Scale-International) (p < .01). Dizziness was a predictor of risk of falls and that it was associated with a greater number of morbidities and previous history of falls. Implementing rehabilitation practices to reduce dizziness symptoms can significantly reduce the risk of falls for institutionalised older adults.

The majority of community-dwelling hip fracture patients return to independent living with minor increase in care needs: a prospective cohort study

INTRODUCTION

Hip fracture patients are fragile, and the majority fail to fully recover to their pre-fracture functional level, resulting in an increase in institutionalization. We aimed to investigate risk factors for being dependent at discharge and for failure to return to independent living 12 months after a hip fracture.

MATERIALS AND METHODS

From 2011 to 2017, all surgically treated hip fracture patients admitted from their own homes were included in this prospective cohort study. Patient characteristics were registered, including age, sex, lifestyle, comorbidities, pre-fracture New Mobility Score (NMS), biochemical measures, fracture type, and surgical method. Dependency was measured at discharge using a cumulated ambulatory score (CAS < 6) and the timed-up-and-go test (TUG > 20 s). At 12 months, patients were interviewed regarding residence, NMS, and care needs. Multivariable logistic regression was used, reporting odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

A total of 2006 patients were included in the study with data regarding their hospital stay and discharge. In all, 1342 patients underwent follow-up at 12 months. The risk factors found to be associated with dependency at discharge were mostly static. Modifiable variables associated with dependency at discharge (CAS < 6) were hypoalbuminemia (OR: 1.94, 95% CI 1.38-2.71), not having been mobilized to standing within 24 h (OR: 1.88, 95% CI 1.12-3.15), and general anesthesia (OR: 1.35, 95% CI 1.07-1.71). Failure to return to independent living at 12 months was found in 10% of the patients, and was primarily associated with patient characteristics and proxy variables for comorbidities, but also with dependency at discharge (CAS < 6).

CONCLUSIONS

Mobilizing patients to standing within 24 h from hip fracture surgery was vital in maximizing short-term functional recovery. Failure to return to independent living was seen in the frailest patients. However, the majority remained in their own home with little increase in care needs.

Determinants of Higher Mortality at Six Months in Patients with Hip Fracture: A Retrospective Study

(1) Background: Hip fracture is a pathology with high mortality, but the lack of a universal adaptation of the factors associated with death makes it difficult to predict risk and implement prevention in this group. This study aimed to identify the factors that determine a higher mortality at six months following hip fracture. (2) Methods: A retrospective longitudinal study, whose study population consisted of patients over 65 years of age. The main variable was mortality at 6 months of fracture. Relevant data related to sociodemographic and clinical variables for subsequent bivariate (χ²) and multivariate analysis were obtained. (3) Results: In all, 665 people participated in the study, 128 of whom died within 6 months of the fracture. The multivariate adjusted analysis demonstrated significant relationships between the main variable and aspects such as institutionalization at discharge (Odds Ratio (OR) = 2.501), a worse overall functional capacity (OR = 2.453) and cognitive capacity (OR = 3.040) at admission, and complications such as heart failure (OR = 5.767) or respiratory infection (OR = 5.308), in addition to the taking of certain drugs and the presence of a greater number of comorbidities. (4) Conclusions: There are certain factors related to higher mortality at six months in patients with hip fracture who are aged 65 years or older.

Cost-effectiveness of group-based exercise to prevent falls in elderly community-dwelling people

BACKGROUND

Clinical studies indicate that strength-balance training for active fall prevention can prevent fractures in older people. The present modelling study evaluates the cost-effectiveness of fall prevention exercise (FPE) provided to independently living older people compared to no intervention in Germany.

METHOD

We designed a Markov model to evaluate the cost-effectiveness of a group-based FPE-program provided to independently living people ≥75 years from the perspective of the German statutory health insurance (SHI). Input data was obtained from public databases, clinical trials and official statistics. The incremental cost-effectiveness ratio (ICER) was presented as costs per avoided hip fracture. Additionally, we performed deterministic and probabilistic sensitivity analyses and, estimated monetary consequences for the SHI in a budget impact analysis (BIA).

RESULTS

For women, the costs per hip fracture avoided amounted to €52,864 (men: €169,805). Results of deterministic and probabilistic sensitivity analyses confirmed the robustness of the results. According to the BIA, for the reimbursement of FPE additional costs of €3.0 million (women) and €7.8 million (men) are expected for the SHI.

CONCLUSIONS

Group-based FPE appears to be no cost-effective option to prevent fall-related hip fractures in independently living elderly. To allow a more comprehensive statement on the cost effectiveness of FPE fracture types other than hip should be increasingly evaluated in clinical trials.

Exploring the Effectiveness of PAC Rehabilitation for Elders with Hip Surgery: A Retrospective Study

Background

Hip fractures are high risk and high-impact events in the elderly population; despite orthopedic hip surgery, the disability and mortality rate remains significant. The National Health Insurance Agency in Taiwan established a fragility fracture PAC rehabilitation program to provide functional recovery for these patients after the surgery. However, the current literature on PAC rehabilitation is outdated, and there is an urgent need for the re-evaluation of the program.

Methods

This is a retrospective cohort study that enrolled 159 patients in the PAC rehabilitation program, followed by hip repair surgery. Outcome measures were the differences in participants’ pre- and post-PAC scores in 1) Barthel index, 2) Numerical Rating Scale (NRS), and 3) Harris Hip Scores (HHS) as surrogate indicators of the functional status, followed by the analysis of subgroups, including sex, age, site of the fracture, type of procedure, and the number of comorbidities.

Results

After completing PAC rehabilitation, 86.2% of the patients successfully returned to the community with either home or out-patient rehabilitation. The re-admission rate was 3.1% and 3.8% in 14-days and in 30-days follow up, respectively. The difference in pre- and post-Barthel index, NRS, and HHS showed significant improvement (p<0.001), without significant variations between the subgroups. Additionally, the Barthel index showed a positive correlation to HHS and a negative correlation to NRS.

Conclusion

This study revealed that the current form of post-surgery fragility fracture PAC program effectively improves functional status, reduces the re-admission rate, and facilitates the patient transition back to the community. The results should improve patients’ and physicians’ confidence in such a program.

Preoperative hypoalbuminemia: Poor functional outcomes and quality of life after hip fracture surgery

AIMS

Hip fracture patients have severe deterioration of their quality of life and function after their injury. Markers of malnutrition such as low albumin and low body mass index (BMI) have been shown to increase mortality and complication rates but their effect on recovery of quality of life and function after hip fracture surgery is unclear. The main aim of this paper is to further investigate if low albumin affects recovery after hip fracture surgery, while additionally studying low BMI as a possible risk factor for poor recovery.

PATIENTS AND METHODS

Retrospective analysis of 971 patients who underwent surgery for fragility hip fractures between January 2012 and December 2016 was performed. Demographic data, preoperative serum albumin and haemoglobin levels, BMI, Charlson Comorbidity Index (CCI), type of surgery (fixation vs replacement) and site of surgery were obtained. Patients were assessed using the Parker Mobility Scale (PMS), Harris Hip Score(HHS), Medical Outcomes Study 36-item Short-Form Health Survey (SF36) at pre-fracture, 6 weeks and 6 months after surgery. HHS was not available pre-operatively. Patients were grouped according to their albumin levels (low ≤35 g/L or normal) and BMI (underweight <18.5 or normal). Univariate and multivariate analyses were performed to examine the association between albumin and BMI and 6-month scores.

RESULTS

On univariate analysis, patients with low albumin ≤35 g/L had lower baseline PMS and SF36 Physical Functioning (PF) score. On multivariate analysis, preoperative hypoalbuminemia was associated with lower 6-month HHS, PMS and SF36 PF scores even after accounting for baseline scores and other confounders. BMI had no effect on 6-month scores.

CONCLUSION

Low albumin (≤35 g/L) is prevalent in elderly hip fracture patients and is associated with slower recovery of function and quality of life after surgery. Low albumin can be a useful prognostic tool to identify patients with poor recovery for further intervention or rehabilitation after hip fracture surgery.

Osteoporosis in older adults

The incidence of fragility fractures increases progressively with advance in age after 50 years, and the phenomenon of population ageing will lead to an increased proportion of the world population having osteoporosis and fractures. The consequences of fractures are more serious in older adults: all low-trauma fractures were associated with increased mortality risk and the risk of a second major osteoporotic fracture after a first one also increased with advance in age. Along with the decrease in bone mineral density, falls play an essential role in the occurrence of fragility fractures in older adults, and the assessment of the risk of falling is part of the fracture risk assessment. Despite advances in the diagnosis of osteoporosis, the assessment of fracture risk, and a wide range of effective anti-osteoporosis medications, with parenteral route which can improve observance, many data indicate that the therapeutic care gap is particularly wide in the elderly in whom the importance and impact of a treatment are high and even more in those living in institutions.

Foot disease and physical function in older adults: A systematic review and meta-analysis

OBJECTIVES

To systematically assess the literature examining the association between foot disease (foot ulceration, infection, critical ischaemia and/or Charcot neuroarthropathy) and physical function in older adults.

METHODS

Literature search of MEDLINE, Embase and CINAHL was performed. Studies were included if foot disease and physical function were assessed in participants of mean or median age ≥ 65 years.

RESULTS

Of 2,574 abstracts screened, 19 studies (13 longitudinal, 6 cross-sectional) reporting on 5634 participants, 43% female, were included. Diabetes-related foot disease and critical ischaemia were most studied (n = 5017, 40% female). In 8 studies with control groups, foot disease was associated with poorer physical function. Meta-analysis of 5 studies (n = 1503, 45% female) found an association between foot disease and poorer physical function (SMD (95% CI): 1.00 (0.40, 1.62), P < 0.001).

CONCLUSION

Foot disease is associated with poorer physical function in older adults. Future research should include broader study populations and intervention strategies.

Functional decline in geriatric rehabilitation ward; is it ascribable to hospital acquired infection? A prospective cohort study

BACKGROUND

In some European countries, including France, older patients with functional decline in acute units are transferred to geriatric rehabilitation units. Some patients may not benefit from their stay in a geriatric rehabilitation unit and paradoxically worsened their functional status. Previous prognostic models of functional decline are based on only baseline parameters. However, some events can occur during rehabilitation and modify the association between baseline parameters and rehabilitation performance such as heart failure episode, falls or hospital-acquired infection (HAI). The incidence of functional decline in these units and factors associated with this decline have not been clearly identified.

METHODS

We used a prospective cohort of consecutive patients aged ≥75 years admitted to a geriatric rehabilitation unit in a French university hospital. The main endpoint was functional decline defined by at least an one-point decrease in Activities of Daily Living (ADL) score during the stay. Baseline social and geriatric characteristics were recorded and comorbidities were sought by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). During follow-up, hospital-acquired infection (HAI) was recorded, as was ADL score at discharge. Multivariate logistic regression and mediation analyses were used to identify factors associated with ADL decrease.

RESULTS

Among the 252 eligible patients, 160 (median age 84 years [interquartile range (IQR) 80-88] had available ADL scores at baseline (median score 7 [IQR 4-10]) and at discharge (median 9 [6-12]). Median CIRS-G score was 11 [8-13], 23 (14%) had a pulmonary HAI; 28 (17.5%) showed functional decline. On multivariable analysis, functional decline was associated with comorbidities (global CIRS-G score, P = 0.02, CIRS-G for respiratory disease [CIRS-G-R] ≥2, P = 0.02, or psychiatric disease, P = 0.02) and albumin level < 35 g/l (p = 0.03). Significant associations were found between functional decline and CIRS-G-R (OR 3.07 [95%CI 1.27-7.41], p = 0.01), between functional decline and pulmonary HAI (OR 3.12 [1.17-8.32],p = 0.02), and between CIRS-G-R and pulmonary HAI (OR 12.9[4.4-37.7], p = 0.0001). Theses associations and the reduced effect of CIRS-G-R on functional decline after adjusting for pulmonary HAI (OR 2.26 [0.83-6.16], p = 0.11) suggested partial mediation of pulmonary HAI in the relation between CIRS-G-R and functional decline.

CONCLUSION

Baseline comorbidities were independently associated with functional decline in patients hospitalized in a geriatric rehabilitation unit. Pulmonary HAI may have mediated this association. We need to better identify patients at risk of functional decline before transfer to a rehabilitation unit and to test the implementation of modern and individual programs of rehabilitation outside the hospital for these patients.

Post-discharge complications in postoperative patients with hip fracture

Hip fractures often occur in elderly people and are a major global health challenge causing many consequences, both in health and socioeconomic costs. This review aimed to identify complications that occur in patients with postoperative hip fracture between 30 days and 60 months after discharge. This review was conducted on articles published from 2005 to 2017 obtained from the EBSCO, PubMed, ProQuest and Google Scholar databases. The literature search followed PRISMA Guidelines. Key search words included the terms: hip fracture, complication, postoperative, community, and nursing. Articles were considered eligible if discussed the complications of hip fracture with surgical treatment, occurring post hospital discharge and the patient was in the community. In this review, 23 articles were included that met the inclusion criteria. There were 16 articles that cohort studies, 3 were retrospective studies, 3 were randomized control trials and 1 article was an observational study. The time of observation varied from 30 days to the longest of 5 years. Quality assessment of the levels of evidence used the Oxford CEBM recommendations. The review results found that postoperative hip fracture patients after discharge still experienced various complications after 30 days and up to 1-3 years post-operation.

[Prognostic factors of mortality one year after a hip fragility fracture. Anoia hip study]

INTRODUCTION

Most of the patients who had a hip fragility fracture are characterized by advanced age, frailty, multimorbidity and high mortality rate into the first year. Our aim is to describe the prognostic factors of mortality one year after a hip fragility fracture.

MATERIAL AND METHODS

Observational prospective study. During the study period we included patients older than 69 years with hip fragility fracture who were admitted to the Acute Geriatric Unit.

RESULTS

We have followed 364 patients, 100 of them died (27.5%). The independent prognostic factors of mortality one year after a hip fragility fracture had been: have a less basis score in Lawton and Brody Scale 0.603 (0.505-0.721) (p< 0.001); have a higher score in Charlson Comorbidity Index 2.332 (1.308-4.157) p = 0.04); have a surgical waiting time ≥ 3 days 3.013 (1.330-6.829) p = 0.008); finding hydroelectrolytic disorders and/or deterioration of glomerular filtration 1.212 (1.017-1.444) p = 0.031) during hospital stay; discriminatory capacity of the area under the curve (AUC) (± 95%): 0.888 (0.880-0.891).

CONCLUSIONS

Prognostic predictors of mortality at one year after a hip fragility fracture are those variables that reflect a worse state of health, complications during hospital stay and a longer surgical waiting time.

The mortality burden of non-trauma fracture for adults with cerebral palsy

Background

Individuals with cerebral palsy (CP) manifest skeletal fragility problems early in life, are vulnerable to non-trauma fracture (NTFx), and have a high burden of premature mortality. No studies have examined the contribution of NTFx to mortality among adults with CP. The purpose of this study was to determine if NTFx is a risk factor for mortality among adults with CP and if NTFx exacerbates mortality risk compared to adults without CP.

Methods

Data from 2011 to 2016 Optum Clinformatics® Data Mart and a random 20% sample Medicare fee-for-service were used for this retrospective cohort study. Diagnosis codes were used to identify adults (18+ years) with and without CP, NTFx, and pre-NTFx comorbidities. Crude mortality rates per 100 person years were estimated. Cox regression estimated hazard ratios (HR and 95% confidence interval [CI]) for mortality, comparing: (1) CP and NTFx (CP + NTFx; n = 1777); (2) CP without NTFx (CP w/o NTFx; n = 12,933); (3) without CP and with NTFx (w/o CP + NTFx; n = 433,560); and (4) without CP and without NTFx (w/o CP w/o NTFx; n = 6.8 M) after adjusting for demographics and pre-NTFx comorbidities.

Results

The 3-, 6-, and 12-month crude mortality rates were highest among CP + NTFx (12-month mortality rate = 6.80), followed by w/o CP + NTFx (12-month mortality rate = 4.91), CP w/o NTFx (12-month mortality rate = 2.15), and w/o CP w/o NTFx (12-month mortality rate = 0.49). After adjustments, the mortality rate was elevated for CP + NTFx for all time points compared to CP w/o NTFx (e.g., 12-month HR = 1.61; 95%CI = 1.29–2.01), w/o CP + NTFx (e.g., 12-month HR = 1.49; 95%CI = 1.24–1.80), and w/o CP w/o NTFx (e.g., 12-month HR = 5.33; 95%CI = 4.42–6.44). There were site-specific effects (vertebral column, lower extremities) on 12-month mortality.

Conclusions

NTFx is associated with an increase of 12-month mortality risk among adults with CP and compared to adults without CP. Findings suggest that NTFx may be a robust risk factor for mortality among adults with CP.

Prognostic factors for discharge to home and residing at home 12 months after hip fracture: an Anoia hip study

OBJECTIVES

Hip fracture is often associated with loss of physical function and institutionalization. The aim of this study is to describe the prognostic factors for discharge to home and residing there 12 months after a hip fracture.

METHODS

A prospective study that includes patients aged ≥ 69 years that live at home before the fracture, admitted from June 1st, 2010, to May 31st, 2013. We registered the demographic data, presurgical function and cognitive assessment, surgical waiting time, type of fracture and complications during hospitalization.

RESULTS

We included 273 patients (mean age 84.8 ± 6.1 years; 80% women), 130 (47.6%) were discharged directly to their own home. The predictors of discharge to home were a lower Geriatrics Dementia Scale score (OR 1.42; 95% CI 1.17-1.71; p < 0.001), a higher Barthel Index score at discharge (OR 1.07; 95% CI 1.05-1.10; p < 0.001) and a longer hospital stay (OR 1.14; 95% CI 1.02-1.27; p = 0.019). At 12 months, 169 (63.5%) were still residing at home. Predictors of residing at home 12 months after the hip fracture were age (OR 1.07; 95% CI 1.02-1.12; p = 0.010), the discharge Barthel Index score (OR 0.96; 95% CI 0.94-0.98; p < 0.001), the Geriatrics Dementia Scale score (OR 1.27; 95% CI 1.05-1.52; p = 0.013), the surgical waiting time (OR 3.42; 95% CI 1.077-10.89; p = 0.037) and Charlson comorbidity index (OR 1.27; 95% CI 1.05-1.55; p = 0.016).

CONCLUSION

Prognostic factors for discharging to home and remaining there 12 months after a hip fracture are those that reflect a better health condition prior to the fracture and better functionality at the hospital discharge for hip fracture.

Low-Trauma Fracture Increases 12-Month Incidence of Cardiovascular Disease for Adults With Cerebral Palsy

Individuals with cerebral palsy (CP) have poor skeletal and cardiovascular health. However, no studies have examined if skeletal fragility enhances cardiovascular disease (CVD) risk for this population. The purpose of this study was to determine whether adults with CP have higher 12-month CVD incidence following a low-trauma fracture compared with adults without CP. Data, from the Optum Clinformatics® Data Mart, were extracted from adults (18+ years) that sustained a low-trauma fracture between 01/01/2012 and 12/31/2016. The primary outcome measure was incident CVD within 12 months following a low-trauma fracture. Cox proportional hazards regression models were used to compare 12-month incident CVD with adjustment for sociodemographics and chronic disease comorbidities. Mean age (SD) at baseline was 54.7 (18.9) for adults with CP (n = 1,025, 43.3% men) and 60.4 (19.7) for adults without CP (n = 460,504, 33.7% men). During the follow-up, 121 adults with CP (11.8%, mean age [SD] = 63.9 [16.3]) and 45,330 adults without CP (9.8%, mean age [SD] = 74.5 [11.9]) developed CVD. In the fully adjusted model, adults with CP had higher 12-month post-fracture CVD incidence (hazard ratio [HR] = 1.63; 95% confidence interval [CI] = 1.37-1.95). When the outcome was stratified by CVD subtype, adults with CP had higher 12-month post-fracture incidence of ischemic heart disease (HR = 1.45; 95% CI = 1.09-1.92), heart failure (HR = 1.68; 95% CI = 1.22-2.31), and cerebrovascular disease (HR = 1.96; 95% CI = 1.54-2.50). Study findings suggest that among adults with CP, low-trauma fracture may enhance 12-month CVD incidence compared with adults without CP. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:803-810, 2020.

Predictive factors associated with mortality in Korean elderly patients with hip fractures

BACKGROUND

It is important to investigate the level of physical function impairment before fracture to predict mortality after hip fracture. This study aimed to examine the predictive factors associated with mortality depending on prefracture physical function impairment among Korean elderly patients.

METHODS

We included 1841 patients aged 65 years and older with hip fractures using osteoporosis-related hip fracture network data from 15 university hospitals in South Korea. The collected data included sociodemographic, nutritional, disease-related, and fracture- and surgery-related factors. For the degree of prefracture physical function impairment, ambulatory ability was classified into community, household, and nonfunctional ambulators. Binominal logistic regression was used to identify the predictive factors for mortality.

RESULTS

Analysis showed that mortality rate at the first follow-up after hip fracture was 4.9%, and most patients (77.7%) were community ambulators before fracture. Sociodemographic (older age, male sex), nutritional (low body mass index, low albumin level before surgery), and fracture- and surgery-related (nonsurgical management, complications after surgery) factors significantly predicted mortality, depending on the prefracture ambulatory status.

CONCLUSIONS

This study emphasizes that nutritional assessment and management as interdisciplinary interventions from hospitalization to follow-ups should be performed to lower malnutrition and mortality risk. Therapeutic management for comorbidities negatively affecting surgery outcomes should be prioritized to reduce postoperative complications and mortality. Surgical treatment should be encouraged if it aligns with the therapeutic goals, even in poor health status.

The mortality burden attributable to nontrauma fracture for privately insured adults with epilepsy

OBJECTIVE

Individuals with epilepsy have poor bone development and preservation throughout the lifespan and are vulnerable to nontrauma fracture (NTFx) and post-NTFx complications. However, no studies have examined the contribution of NTFx to mortality among adults with epilepsy. The objective was to determine whether NTFx is a risk factor for mortality among adults with epilepsy.

METHODS

Data from 2011 to 2016 were obtained from Optum Clinformatics Data Mart, a nationwide claims database from a single private payer in the United States. Diagnosis codes were used to identify adults (≥18 years old) with epilepsy, NTFx, and covariates (demographics and pre-NTFx cardiovascular disease, respiratory disease, diabetes, chronic kidney disease, cancer). Crude mortality rate per 100 person-years was estimated. Cox regression estimated hazard ratios (HRs) and 95% confidence intervals (CIs) were determined for mortality, comparing epilepsy and NTFx (EP + NTFx; n = 11 471), epilepsy without NTFx (EP without NTFx; n = 50 384), without epilepsy and with NTFx (without EP + NTFx; n = 423 041), and without epilepsy and without NTFx (without EP without NTFx; n = 6.8 million) after adjusting for covariates.

RESULTS

The 3-, 6-, and 12-month crude mortality rates were highest among EP + NTFx (12-month mortality rate = 8.79), followed by without EP + NTFx (12-month mortality rate = 4.80), EP without NTFx (12-month mortality rate = 3.06), and without EP without NTFx (12-month mortality rate = 0.47). After adjustments, the mortality rate was elevated for EP + NTFx for all time points compared to EP without NTFx (eg, 12-month HR = 1.70, 95% CI = 1.58-1.85), without EP + NTFx (eg, 12-month HR = 1.41, 95% CI = 1.32-1.51), and without EP without NTFx (eg, 12-month HR = 5.23, 95% CI = 4.88-5.60). Stratified analyses showed higher adjusted HRs of 12-month mortality for EP + NTFx for all NTFx sites (ie, vertebral column, hip, extremities), all age categories (young, middle-aged, older), and for both women and men.

SIGNIFICANCE

Among adults with epilepsy and compared to adults without epilepsy, NTFx is associated with a higher 12-month mortality rate. Findings suggest that NTFx may be a robust risk factor for mortality among adults with epilepsy.

Survival Analysis of Hospitalized Elderly People with Fractures in Brazil Over One Year

Objective: This study analyzes the causes of death, survival, and other related factors in hospitalized elderly people with fractures over the course of one year. Methods: We followed 376 fracture patients for one year in a prospective cohort study to a reference hospital in central Brazil. The Cox regression model was used to analyze factors associated with survival. Results: The results indicate that the one-year mortality rate was high (22.9%). The independent factors linked to lower overall survival were as follows: patients aged ≥80 years with previous intensive care unit (ICU) admission and presence of comorbidities (diabetes mellitus [DM] and dementia). Conclusion: Our study results may contribute to a better understanding of the impact of fractures on the elderly population and reinforce the need to oversee age-groups, diabetic patients, and patients with complications during hospitalization.

Three-year National report from the Gruppo Italiano di Ortogeriatria (GIOG) in the management of hip-fractured patients

BACKGROUND

Hip fractures (HF) are a major issue worldwide. We aimed at evaluating the practices in delivering care to patients with HF among several Italian Orthogeriatric centers.

METHODS

The study took place from February 2016 to July 2018. Seven performance indicators (pre-surgical cognitive assessment, surgery performed ≤ 48 h from fracture, removal of urinary catheter/absence of delirium/start of physiotherapy on the first post-operative day, prescription of bone protection at discharge, and discharge toward rehabilitation) were collected.

RESULTS

The 14 participating hospitals totally recruited 3.017 patients. Patients were old (median age 86 years; Inter Quartile Range [IQR] 80-90), mostly females (77%). Nearly 55% of them were already impaired in mobility and about 10% were nursing home residents. Median time-to-surgery was 41 h (IQR 23-62). Models of care greatly varied among centers, only 49.3% of patients being co-managed by geriatricians and orthopedics. There was high variability across centers in four indicators ("pre-surgical cognitive assessment", "bone protection prescription", "use of urinary catheter" and "start of physiotherapy"), moderate in two indicators ("surgery performed ≤ 48 h from fracture" and "discharge toward rehabilitation" and low in one ("absence of delirium on day following surgery"). Comparison with international studies suggests very different ways of providing care to HF Italian patients.

CONCLUSIONS

The study results suggest high inter-center variability in the key-performance indicators, and different approaches in providing care to our HF patients in comparison to other countries. A National debate on the topic is required in Italy to harmonize practices of orthogeriatric care.

A population-based study of 2347 fall-related injuries among older people in a Finnish emergency department

PURPOSE

Fall-related injuries are a significant cause of morbidity, mortality and functional decline among older people. The aim of this study is to analyze the incidence of fall-related emergency department (ED) visits and compare the characteristics of single and recurrent fallers in a population-based sample.

METHODS

Consecutive patients aged ≥ 80 years and living in the Tampere city region who visited collaborative emergency department within a two-year study period (1 January 2015 to 31 December 2016) due to fall-related injury were included. The incidence of fall-related injuries and recurrent falls was calculated using population statistics.

RESULTS

A total of 6915 ≥ 80-year-old patients visited our ED 17,769 times during the study period. Thirteen percent of these visits (n = 2347, median 87 years, 80-103 years; 74% female) were fall-related. The incidence of fall-related ED visits increased from 94/1000 person-years to 171/1000 among those aged 80-89 years and ≥ 90 years, respectively. Twenty-four percent of patients had recurrent falls (range 2-5) during the observational period. Twenty-five percent of those discharged home had a subsequent fall-related injury within one month after the index visit. The distribution of diagnoses was similar among those with single and recurrent falls.

CONCLUSION

Fall-related injuries are a significant health issue. Almost one in eight of all ED visits were fall-related, and 24% of patients had recurrent fall-related injuries. The risk of subsequent injury was high during the first month after the first injury, emphasizing the need to intervene with the fall risk promptly.

The effect of low-trauma fracture on one-year mortality rate among privately insured adults with and without neurodevelopmental disabilities

BACKGROUND

Individuals with neurodevelopmental disabilities (NDDs) have poor development and preservation of skeletal health throughout the lifespan, and are especially vulnerable to low-trauma fracture and post-fracture health complications. However, no studies have examined if adults with NDDs have greater post-fracture mortality risk compared to adults without NDDs. The purpose of this study was to determine whether adults with NDDs have greater 12-month mortality rates following a low-trauma fracture compared to adults without NDDs.

METHODS

Data from 2011 to 2017 was leveraged from Optum Clinformatics® Data Mart; a nationwide claims database from a single private payer in the U.S. Data were extracted from adults (18+ years) with and without NDDs that sustained a low-trauma fracture between 01/01/2012-12/31/2016, as well as pre-fracture chronic diseases (i.e., cardiovascular diseases, cerebrovascular diseases, diabetes, chronic obstructive pulmonary diseases, cancer). Mortality rate was estimated for adults with and without NDDs, and the mortality rate ratio (RR) and 95% confidence interval (CI) was calculated. Cox regression was used to estimate hazard ratio (HR) and 95% CI for 1-, 3-, 6-, and 12-month post-fracture mortality rates between adults with and without NDDs after adjusting for age, sex, race, U.S. region, and pre-fracture chronic diseases.

RESULTS

Mean age (SD) at baseline was 56.7 (20.6) for adults with NDDs (n = 3749; 45.2% men) and 63.9 (19.2) for adults without NDDs (n = 585,910; 34.4% men). During the 12-month follow-up period, 182 adults with NDDs (mean age [SD] = 69.8 [14.7]; 46.2% men) and 25,456 adults without NDDs (mean age [SD] = 78.9 [9.8]; 38.3% men) died. Crude mortality rate was not different between adults with and without NDDs for any time points (e.g., 12-months: 5.40 vs. 4.96 per 100 person years; RR = 1.09; 95% CI = 0.94-1.26); however, it was greater for adults with intellectual disabilities compared to adults without NDDs (RR = 1.46; 95% CI = 1.23-1.79). After adjustments, adults with NDDs had greater post-fracture mortality rates for 3-, 6-, and 12-month time points (e.g., 12-months: HR = 1.46; 95% CI = 1.27-1.69). When stratified by the type of NDD, adults with intellectual disabilities and adults with autism spectrum disorders, but not adults with cerebral palsy, had greater 12-month post-fracture mortality risk. When stratified by fracture location, lower extremities were associated with greater crude mortality rate (RR = 1.69; 95% CI = 1.22-2.35) and adjusted mortality risk (HR = 2.41; 95% CI = 1.73-3.35), while upper extremities were associated with greater adjusted mortality risk (HR = 1.76; 95% CI = 1.23-2.50) for adults with vs. without NDDs.

CONCLUSIONS

Among privately insured adults with NDDs, low-trauma fracture is associated with greater mortality risk within 1 year of the fracture event, even after adjusting for pre-fracture chronic diseases. Study findings suggest the need for earlier fracture prevention strategies and improved post-fracture healthcare management.

Frailty defined by 19 items as a predictor of short-term functional recovery in patients with hip fracture

INTRODUCTION

Many hip fracture patients have decreased functional status inhibiting recovery to pre-fracture functional status. The prevalence of frailty in patients with hip fracture is high, but little is known how frailty is associated with functional recovery. The aim of this study was to determine whether frailty can predict functional recovery and clinical outcomes during the acute phase in hip fracture.

PATIENTS AND METHODS

This study was retrospective observational study from two acute hospitals. Participants were recruited from hip fracture patients who underwent surgery. The main exposure was frailty defined using 19-item modified Frailty Index (mFI). The main outcome was functional recovery, evaluated by postoperative efficiency on the motor-Functional Independence Measure (FIM) score. Secondary outcomes included postoperative complication and discharge disposition. Multiple logistic regression analyses were performed using each outcome as a dependent variable and mFI as an independent variable.

RESULTS

Sample included 274 patients (mean age 83.7 ± 7.4 years, female 80.7%). Patients with higher mFI exhibited lower functional recovery, defined by efficiency on the motor-FIM score, and tended to run into complications and not return home (P < .001). In multiple logistic regression analyses, higher mFI was significantly associated with increased likelihood of lower functional recovery (odds ratio [OR], 1.60; 95% CI, 1.32-1.93; P < .001), occurrence of postoperative complication (OR, 1.32; 95% CI, 1.13-1.54; P < .001) and not returning home (OR, 1.77; 95% CI, 1.38-2.26; P < .001).

CONCLUSIONS

Frailty defined by 19-item mFI can predict short-term functional recovery during acute phase following hip fracture. Frailty is also associated with postoperative complication and discharge disposition.

Osteoporosis Epidemiology Among Adults With Cerebral Palsy: Findings From Private and Public Administrative Claims Data

Individuals with cerebral palsy (CP) have an increased risk for the early development of osteoporosis; however, little is known about the epidemiology of osteoporosis for adults with CP, which is vital to inform clinical practice for osteoporosis prevention, treatment, and management. The purpose of this cross-sectional study was to determine sex-stratified prevalence of osteoporosis among adults with CP, as compared with adults without CP. Data from 2016 were extracted from Optum Clinformatics Data Mart (private insurance administrative claims data) and a random 20% sample from the fee-for-service Medicare (public insurance administrative claims data). Diagnostic codes were used to identify CP and osteoporosis diagnoses. Sex-stratified prevalence of osteoporosis was compared between adults with and without CP for the following age groups: 18 to 30, 31 to 40, 41 to 50, 51 to 60, 61 to 70, and >70 years of age. The overall prevalence of osteoporosis was 4.8% for adults without CP (n = 8.7 million), 8.4% for privately insured adults with CP (n = 7,348), and 14.3% for publicly insured adults with CP (n = 21,907). Women and men with CP had a higher prevalence of osteoporosis compared with women and men without CP for all age groups. Finally, publicly insured women and men with CP had a higher prevalence of osteoporosis compared with privately insured women and men with CP for all age groups, except for the similar prevalence among the 18- to 30-year age group. These findings suggest that osteoporosis is more prevalent among adults with CP compared with adults without CP. Study findings highlight the need for earlier screening and preventive medical services for osteoporosis management among adults with CP. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Factors Associated with Sarcopenia and 7-Year Mortality in Very Old Patients with Hip Fracture Admitted to Rehabilitation Units: A Pragmatic Study

Background: Admitted bedridden older patients are at risk of the development of sarcopenia during hospital stay (incident sarcopenia). The objective of this study was to assess the factors associated with sarcopenia (incident and chronic) and its impact on mortality in older people with hip fracture. Methods: A multicenter, pragmatic, prospective observational study was designed. Older subjects with hip fracture admitted to two rehabilitation units were included. Sarcopenia was assessed at admission and at discharge according to the revised EWGSOP (European Working Group on Sarcopenia in Older People) consensus definition. The mortality was evaluated after 7 years of follow-up. Results: A total of 187 subjects (73.8% women) age 85.2 ± 6.3 years were included. Risk factors associated to incident and chronic sarcopenia were undernutrition (body mass index—BMI and Mini Nutritional Assessment−Short Form—MNA-SF), hand-grip strength and skeletal muscle index. During follow-up 114 patients died (60.5% sarcopenic vs. 39.5% non-sarcopenic, p = 0.001). Cox regression analyses showed that factors associated to increased risk of mortality were sarcopenia (HR: 1.67, 95% CI 1.11–2.51) and low hand-grip strength (HR: 1.76, 95% CI 1.08–2.88). Conclusions: Older patients with undernutrition have a higher risk of developing sarcopenia during hospital stay, and sarcopenic patients have almost two times more risk of mortality than non-sarcopenic patients during follow-up after hip fracture.

Influence of hospital adverse events and previous diagnoses on hospital care cost of patients with hip fracture

Previous diagnoses of patients with hip fracture influence the hospitalization cost of these patients, either directly or by increasing the risk of in-hospital adverse events associated with increased costs.

PURPOSE

To investigate how previous diagnoses influence the occurrence of in-hospital adverse events and how both factors impact on hospital costs.

METHODS

This is a retrospective analysis of the hospital Minimum Basic Data Set. Patients aged 70 years or older admitted for hip fracture (HF) at a single University Hospital between January 2012 and December 2016. Both, previous diagnoses and adverse events, were defined according to the International Classification of Diseases (ICD-9/ICD-10). The anticipated cost of each admission was calculated based on diagnosis-related groups and using the "all patients refined" method (APR-DRG). The occurrence of adverse events during hospital stay was assessed by excluding all diagnoses present on admission.

RESULTS

The record included 1571 patients with a mean (SD) age of 84 years. The most frequent previous diagnoses were diabetes (n = 432, 27.5%) and dementia (n = 251, 16.0%), and the most frequent adverse events were delirium (n = 238, 15.1%) and anemia (n = 188, 12.0%). The mean (SD) total acute care costs per patient were €8752.1 (1864.4). The presence of heart failure, COPD, and kidney disease at admission significantly increased the hospitalization cost. In-hospital adverse events of delirium, cardiac events, anemia, urinary tract infection, and digestive events significantly increased costs. The multivariate analyses identified kidney disease as a previous diagnosis significantly contributing to explain an increase in hospitalization costs, and delirium, cardiac disease, anemia, urinary infection, respiratory event, and respiratory infection as in-hospital adverse events significantly contributing to an increase of hospitalization costs.

CONCLUSIONS

Although few baseline comorbidities have a direct impact on hospitalization costs, most previous diagnoses increase the risk of in-hospital adverse events, which ultimately influence the hospitalization cost.

Racial differences in skeletal fragility but not osteoarthritis among women and men with cerebral palsy

Background

Adults with cerebral palsy (CP) have increased risk for skeletal fragility and osteoarthritis. However, racial differences in these outcomes have not been examined. Such knowledge could improve patient-specific clinical care for the prevention and management of these conditions. The purpose of this study was to determine if there were racial differences in the prevalence of osteoporosis, all-cause fracture, and osteoarthritis among young and middle-aged adults with CP.

Methods

Data from 2016 were extracted from a random 20% sample of the Medicare fee-for-service database. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify 18-64 year olds with CP, as well as osteoporosis, all-cause fracture, osteoarthritis, and neurodevelopmental and noncommunicable disease comorbidities.

Results

Of the 16,488 adults with CP, 13,334 were White, 2477 were Black, and 677 were Hispanic. The age-standardized prevalence of osteoporosis (women: 12.9%, 9.0%, 8.3%, respectively; men: 9.2%, 4.8%, 7.9%, respectively) and fracture (women: 7.4%, 4.2%, 9.9%; men: 6.0%, 2.3%, 6.0%) was lower for Black adults with CP compared to White adults with CP (all p < 0.005). No racial differences were observed for age-standardized prevalence of osteoarthritis (women: 13.6%, 14.4%, 9.6%; men: 10.7%, 10.4%, 12.7%). The racial differences between Black and White adults with CP remained even after adjusting for age, U.S. region, neurodevelopmental comorbidities, and several noncommunicable diseases for osteoporosis (women: OR = 0.66, 99.5% CI = 0.48-0.91; men: OR = 0.51, 99.5% CI = 0.35-0.75) and fracture (women: OR = 0.57, 99.5% CI = 0.37-0.89; men: OR = 0.39, 99.5% CI = 0.23-0.68).

Conclusions

Study findings suggest racial differences in skeletal fragility among young and middle-aged adults with CP, with White women and men with CP having greater risk compared to Black women and men with CP. This study found no evidence of racial differences in the prevalence of osteoarthritis.

Adults with Cerebral Palsy have Higher Prevalence of Fracture Compared with Adults Without Cerebral Palsy Independent of Osteoporosis and Cardiometabolic Diseases

Individuals with cerebral palsy (CP) have an increased risk of fracture throughout their lifespan based on an underdeveloped musculoskeletal system, excess body fat, diminished mechanical loading, and early development of noncommunicable diseases. However, the epidemiology of fracture among adults with CP is unknown. The purpose of this cross-sectional study was to determine the prevalence of fracture among a large sample of privately insured adults with CP, as compared with adults without CP. Data were from the Optum Clinformatics Data Mart (Eden Prairie, MN, USA), a deidentified nationwide claims database of beneficiaries from a single private payer. Diagnostic codes were used to identify 18- to 64-year-old beneficiaries with and without CP and any fracture that consisted of osteoporotic pathological fracture as well as any type of fracture of the head/neck, thoracic, lumbar/pelvic, upper extremity, and lower extremity regions. The prevalence of any fracture was compared between adults with (n = 5,555) and without (n = 5.5 million) CP. Multivariable logistic regression was performed with all-cause fracture as the outcome and CP group as the primary exposure. Adults with CP had a higher prevalence of all-cause fracture (6.3% and 2.7%, respectively) and fracture of the head/neck, thoracic, lumbar/pelvic, upper extremity, and lower extremity regions compared with adults without CP (all p < 0.01). After adjusting for sociodemographic and socioeconomic variables, adults with CP had higher odds of all-cause fracture compared with adults without CP (OR 2.5; 95% CI, 2.2 to 2.7). After further adjusting for cardiometabolic diseases, adults with CP had higher odds of all-cause fracture compared with adults without CP (OR 2.2; 95% CI, 2.0 to 2.5). After further adjusting for osteoporosis, adults with CP still had higher odds of all-cause fracture compared with adults without CP (OR 2.0; 95% CI, 1.8 to 2.2). These findings suggest that young and middle-aged adults with CP have an elevated prevalence of all-cause fracture compared with adults without CP, which was present even after accounting for cardiometabolic diseases and osteoporosis. © 2019 American Society for Bone and Mineral Research.

Prognostic Role of Serum Albumin, Total Lymphocyte Count, and Mini Nutritional Assessment on Outcomes After Geriatric Hip Fracture Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Hip fracture is a significant health risk for older adults and malnutrition indicates hip fracture risk.

METHODS

We evaluated whether nutrition status could predict clinical outcomes and mortality after hip fracture surgery in older adults. MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched for studies published until July 1, 2018, in patients with serum albumin or total lymphocyte count (TLC) at admission, nutritional status by Mini Nutritional Assessment (MNA), and in-hospital follow-up. Data extracted were analyzed using random-effects or fixed-effects models.

RESULTS

Nineteen studies with 34,363 adults aged 74-85 years receiving hip fracture surgery were eligible for inclusion. Among these studies, 13 were screened for low albumin, 4 were evaluated for TLC, and 4 for nutritional status by MNA. Hypoalbuminemia was significantly associated with higher total mortality and higher risk of in-hospital death (both P < .001). Low TLC and MNA results "at risk of malnutrition" (hazard ratio, 1.67; 95% confidence interval = 1.28-2.18) and "malnourished" nutritional status (hazard ratio, 2.65; 95% CI = 1.81-3.88) also were significantly associated with higher total mortality (all P < .001).

CONCLUSION

Low serum albumin level is a sole indicator for increased risk of in-hospital death, postoperative complications, and total mortality after hip fracture surgery in older adults. Low TLC and malnutrition classified by MNA predict increased mortality. These indicators provide valuable prognostic information and routine use may be prudent.

Factors Related to the Institutionalization of Older Aged Individuals Using Home- and Community-Based Care Services: Data From the South Korea Long-Term Care Insurance Program, 2008-2013

South Korea introduced a public long-term care insurance (LTCI) program in response to its rapidly aging population. This study analyzed the association between living arrangement and caregiver type with institutionalization in LTCI grade 1 (very severe limitations), 2 (severe limitations), and 3 (moderate limitations) beneficiaries using data from the LTCI cohort, 2008 to 2013. The dependent variable was alteration status from home to institutional care within 1 year of receiving home service. Independent variables were living arrangement and primary caregiver type. The analysis was conducted using the generalized estimating equation model. Higher likelihoods of institutionalization were found in individuals living with a non-family member compared to individuals living with their spouses. Individuals without a caregiver or with a paid caregiver were also more likely to experience institutionalization than individuals with a spouse primary caregiver. Our findings underscore the importance of monitoring identified vulnerable groups of individuals to attain LTCI sustainability and enhance elderly quality of life.

Influence of demographic and clinical characteristics of elderly patients with a hip fracture on mortality: A retrospective, total cohort study in North-East Spain

IMPORTANCE

The increased mortality after hip fracture (HF) is caused by multiple factors, and large samples are needed to assess the weight of each factor. To date, few studies have investigated these factors through a total cohort approach, and the complexity of underlying medical conditions has not been considered.

OBJECTIVE

To investigate the influence of demographic and clinical characteristics on increased mortality risk in elderly patients with hip fracture (HF).

DESIGN

Retrospective, total cohort study collecting 4-year data.

SETTING

All hospitals and primary care units owned by, or associated with, Catalonia's local health department (CatSalut) (north-east Spain).

PARTICIPANTS

All patients aged ≥65 years, admitted to Catalan hospitals from CatSalut because of a HF between 1st January 2012 and 31st December 2015.

EXPOSURE

Hip fracture.

MAIN OUTCOME MEASURES

The main outcome was survival. Measures regarding demographic and clinical characteristics at the moment of hospital admission included age, sex, osteoporosis treatment, previous fractures, type of intervention, nutritional status, and comorbidities. Patients were stratified using the Adjusted Morbidity Groups (GMA) risk assessment tool.

RESULTS

Of the 30,552 patients included in the study sample, 10,439 (34%) died during follow-up, 6821 (22%) within the first year after hospital admission. Mean (SD) age was 84 (7) years; 75% were female. Baseline factors with greater influence on survival were age (HRs 1.44 [95% CI 1.22-1.70], 2.38 [2.03-2.79], and 4.38 [3.73-5.15] for age groups 70-79, 80-89, and >89, respectively), underweight (HR 1.65 [1.36-2.01]), lack of surgical intervention (HR 2.64 [2.47-2.83]), and very high risk stratum of GMA risk (HR 1.58 [1.45-1.73]). Vitamin D/calcium supplementation and osteoporosis treatment showed a significant but moderate influence on mortality (HRs 0.84 (0.79-0.88) and 0.92 [0.85-0.99], respectively).

CONCLUSIONS AND RELEVANCE

In elderly patients with HF, age and health status factors at hospital admission have the greatest impact on mortality risk after hospital admission. Our findings encourage a comprehensive intervention aimed at improving underlying medical conditions of HF patients.

Relative survival following hemi-and total hip arthroplasty for hip fractures in Sweden

BACKGROUND

Hip fractures are a common problem in the ageing population. Hip arthroplasty is the common treatment option for displaced intracapsular neck of femur fractures. Even though hip replacements are successful in restoring mobility, reducing pain and diminishing loss of health-related quality of life, the potential impact of a hip fracture on life expectancy as well as the postoperative mortality need consideration. The purpose of this study was to describe the mid-term relative survival rate for a cohort of Swedish patients whom underwent total- or hemiarthroplasty surgery following hip fracture. We also explored whether the survival rate is prosthesis-type specific and influenced by comorbidities, sex, socioeconomic and surgical factors.

METHODS

Using prospectively collected information of the Swedish Hip Arthroplasty Register-linked database we identified 43,891 patients operated between 2005 and 2012. Patient- and surgery-specific data in combination with socio-economic data were available for this analysis. We studied relative survival rate and used multivariable modelling with Cox Proportional Hazards Model in Transformed Time.

RESULTS

Compared to the Swedish general population the baseline excess hazard was very high in the first half year after the operation, thereafter the excess hazard decreased but remained non-negligible through the 8 years' follow-up period. The mortality rate of males was higher compared to women. Higher Elixhauser comorbidity index (ECI) was associated with worsening survival. However, patients who had ECI = 0 had higher mortality than patients with ECI =1 the first 420 days post fracture. Patients with a hemiarthroplasty had a worse survival than patients with a total hip arthroplasty. Of the hospital types considered university hospitals had lower survival rate. Younger patients had a greater loss of expected life span than patients who suffer hip fracture in their more advanced ages.

CONCLUSIONS

Swedish hip fracture patients who undergo arthroplasty surgery had a high excess hazard of dying in the first half year following surgery, and this excess hazard never subsided to negligible levels at least up to 8 years after surgery. Interestingly having no prior record of illnesses worsened the initial mortality. Men living alone had the highest long-term excess mortality.

Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture

Malnutrition is very prevalent in geriatric patients with hip fracture. Nevertheless, its importance is not fully recognized. The objective of this paper is to review the impact of malnutrition and of nutritional treatment upon outcomes and mortality in older people with hip fracture. We searched the PubMed database for studies evaluating nutritional aspects in people aged 70 years and over with hip fracture. The total number of studies included in the review was 44, which analyzed 26,281 subjects (73.5% women, 83.6 ± 7.2 years old). Older people with hip fracture presented an inadequate nutrient intake for their requirements, which caused deterioration in their already compromised nutritional status. The prevalence of malnutrition was approximately 18.7% using the Mini-Nutritional Assessment (MNA) (large or short form) as a diagnostic tool, but the prevalence was greater (45.7%) if different criteria were used (such as Body Mass Index (BMI), weight loss, or albumin concentration). Low scores in anthropometric indices were associated with a higher prevalence of complications during hospitalization and with a worse functional recovery. Despite improvements in the treatment of geriatric patients with hip fracture, mortality was still unacceptably high (30% within 1 year and up to 40% within 3 years). Malnutrition was associated with an increase in mortality. Nutritional intervention was cost effective and was associated with an improvement in nutritional status and a greater functional recovery. To conclude, in older people, the prevention of malnutrition and an early nutritional intervention can improve recovery following a hip fracture.

Development and validation of a prognostic index for 6- and 12-month mortality in hospitalized older adults

BACKGROUND/AIM

Estimation of mortality in elderly patients is difficult yet very important when planning care. Previous tools are complicated or do no take into account some major determinants of mortality (i.e., frailty). We designed a simple, accurate, and non-disease-specific tool to predict individual mortality risk after hospital discharge in older adults.

METHODS

Patients admitted to the Acute Geriatric Unit were assessed at adission and at discharge and contacted 6 and 12 months later. Determinants of mortality were obtained. Using multivariable analysis, beta coeffcicients were calculated to build 2 scores able to predict mortality at 6 and 12 months after discharge. The scores were tested on a sample comprising 75% of the patients, who were randomly selected; they were validated using the remaining 25%. Discrimination was assessed using ROC curves. Scores were calculated for each patient and divided into tertiles. Survival analysis was performed.

RESULTS

Determinants of mortality at 6 months were dependent ambulation at baseline, full dependence at discharge, length of stay, pluripatology, pressure ulcers, low grip strength, malignacy, and male gender. At 12 months the determinants were: dependent amblation at baseline, full dependence at discharge, pluripatology, low BMI, low grip strength, heart failure, malignacy, and male gender. Discrimination and calibration were excellent. Survival analysis demonstrated different survival trajectories (p<0.001) for each tertile in both scores.

CONCLUSIONS

Our incices provide accurate prognostic information in elderly patients after discharge. They can be calculated easily, quickly and do not require technical or laboratory support, thus endorsing their value in dalily clinical practice.

Access to Anti-osteoporosis Medication after Hip Fracture in Korean Elderly Patients

PURPOSE

This study aims to evaluate access to anti-osteoporosis medication (AOM) and the factors affecting their prescription for Korean elderly patients with a hip fracture.

METHODS

A cross-sectional study was conducted on hip fracture patients aged 65 years or more using national-level data from 2013 to 2014. The prescription rates of AOM within 3 months after hip fracture were determined and the factors affecting AOM prescriptions were identified through multivariate logistic regression.

RESULTS

A total of 6307 elderly patients were selected from a national medical insurance database, giving an estimated 15,768 patients nationally in a nine-month period. One-third of the patients (33.5%) received an AOM prescription and only 9.4% of the patients were prescribed an AOM with calcium and vitamin D supplements. Being 80 years and older (adjusted OR, 0.78; 95% CI, 0.70-0.88) and having three or more comorbid diseases (adjusted OR, 0.66; 95% CI, 0.55-0.78) were associated with a lower likelihood of an AOM prescription. Female sex (adjusted OR, 2.54; 95% CI, 2.17-2.98), an osteoporosis diagnosis (adjusted OR, 2.50; 95% CI, 2.15-2.91), concurrent thiazolidinedione therapy (adjusted OR, 2.11; 95% CI, 1.29-3.45) and a dual-energy X-ray absorptiometry (DXA) examination after hip fracture (adjusted OR 4.11; 95% CI, 3.67-4.62) were all significant predictive factors for AOM prescription. Bisphosphonates were the most frequently prescribed AOMs (92.2%).

CONCLUSIONS

The AOM prescription rate for elderly patients with hip fractures was suboptimal in Korea. Factors affecting an AOM prescription were age, sex, clinical comorbidity, osteoporosis status, concurrent thiazolidinedione therapy, and receiving a DXA examination after hip fracture.

Effectiveness of nutritional supplementation on sarcopenia and recovery in hip fracture patients. A multi-centre randomized trial

BACKGROUND AND OBJECTIVES

Functional deterioration and reduced mobility in elderly patients with a hip fracture are associated with a loss of both muscle mass and function (sarcopenia). The aim of this study was to assess whether oral nutritional supplementation (ONS) improves muscle mass and nutritional markers (BMI, proteins) in elderly patients with hip fracture.

METHODS

Patients aged 65 years and over with hip fractures admitted to either of two rehabilitation facilities were included. Patients with diabetes, with Barthel index scores <40 prior to the fracture or with pathological fractures were excluded. A random-numbers generator was used to randomly allocate patients to the intervention group (IG) or the control group (CG). Those in the IG received a standard diet plus ONS in the form of two bottles a day of β-hydroxy-β-methylbutyrate (HMB), while those in the CG received a standard diet only. The intervention was not blinded. In order to assess changes in body mass index (BMI), anthropometric parameters were recorded at both admission and discharge. Patients' functional situation was evaluated using the Barthel index (BI) and the Functional Ambulation Categories (FAC) score. Muscle mass was assessed using bioelectrical impedance analysis, which allowed us to calculate appendicular lean mass (aLM). The outcome variable was the difference between aLM upon discharge, minus aLM upon admission (Δ-aLM).

RESULTS

Of the 107 randomised patients (IG n55, CG n52), 49 finished the study in the IG and 43 in the CG. BMI and aLM were stable in IG patients, whilst these parametres decreased in the CG. A significant difference was observed between the two groups (p<0.001, and p=0.020 respectively). The predictive factors for Δ-aLM were ONS (p=0.006), FAC prior to fracture (p<0.001) and BI prior to fracture (p=0.007). The concentration of proteins (p=0.007) and vitamin D (p.001) had increased more in the IG than in the CG.

CONCLUSION

A diet enriched in HMB improves muscle mass, prevents the onset of sarcopenia and is associated with functional improvement in elderly patients with hip fractures. Orally administered nutritional supplements can help to prevent the onset of sarcopenic obesity.

TRIAL REGISTRATION

www.clinicaltrials.gov identifier: NCT01404195, registered 22 July 2011, HYPERPROT-GER Study.