Recommendations for the acute and long-term medical management of low-trauma hip fractures

Hip fracture care and national systems in Israel and South Africa

Despite the same latitude on earth, Israel and South Africa have a wide variety of healthcare systems and approaches. Israel is a developed country with life expectancy within the first decile of the modern world. South Africa is a developing country where available resources and health care varies greatly across the country. Israeli policy makers have realized in 1999 the importance of early surgery for hip fractures as the single most important factor contributing to decreased mortality. After an introduction of a newer reimbursement system in 2004, and public advertising of early hip fracture treatment as a quality tag for hospitals, in more than 85% of the cases patients are operated on early (within 8 hours) with a significant decrease in mortality. However, other issues such as patient preparation, rehabilitation, and prevention are still at their beginning. South Africa deals with significant challenges with high energy hip fractures in a younger population, although osteoporosis is on the rise in certain parts of the country. Due to limited resources and distances, time to surgery differs among hospital systems in the country. In public hospitals, a delay up to a week may be common, whereas in private hospitals most patients are operated early within 48 to 72 hours. Due to decreased life expectancy, arthroplasty is more aggressively used in displaced femoral neck fractures. Rehabilitation is mostly done within the families. Prevention and orthogeriatric teamwork are not being commonly practiced. Generally speaking, more attention to hip fractures is needed from healthcare funders.

Opioid use after hip fracture surgery: A Danish nationwide cohort study from 2005 to 2015

BACKGROUND

There is currently a knowledge gap regarding persistent opioid use after hip fracture surgery. Thus, opioid use within a year after hip fracture surgery in patients with/without opioid use before surgery was examined.

METHODS

This population-based cohort study included all patients (aged ≥ 65) undergoing primary hip fracture surgery in Denmark (2005-2015) identified from the Danish Multidisciplinary Hip Fracture Database. Opioid use was assessed from The Danish National Health Service Prescription Database as redeemed prescriptions. The proportion of patients with ≥1 opioid prescription was computed within 6 months before surgery and each of four 3-month periods (quarters) after surgery, among patients alive first day in each period. Proportion differences (95% CI) were calculated for each quarter compared to before surgery. Proportions were calculated for users and nonusers before surgery, including initiators after first quarter.

RESULTS

This study included 69,456 patients. Proportion differences of opioid users were 35.0 (95% CI 34.5-35.5), 7.0 (95% CI 6.5-7.5), 2.9 (95% CI 2.4-3.4) and 1.4 percentage-points (95% CI 0.9-1.9) the four quarters after surgery compared to before. Among opioid nonusers before surgery, 54.7% (95% CI 54.3-55.1), 21.8% (95% CI 21.4-22.2), 17.8% (95% CI 17.4-18.2) and 16.8% (95% CI 16.4-17.2) were opioid users in 1st-4th quarter after surgery. However, 8.5% (95% CI 8.2-8.7) of the nonusers before surgery in 4th quarter initiated opioid use more than a quarter after surgery.

CONCLUSIONS

The proportion of opioid users increased after hip fracture surgery and was 1.4 percentage-points increased in fourth quarter compared to before. Of opioid nonusers before surgery, 16.8% were opioid users fourth quarter after surgery.

SIGNIFICANCE

Opioid use 1 year after hip fracture surgery is common, both in patients who were opioid users and nonusers before the surgery. These significant findings point out the need for indication of benefits and risks of opioid use in the acute and long-term management of patients undergoing hip fracture surgery.