Hip fracture care and national systems in Israel and South Africa

Factors influencing the achievement of early surgery in proximal femoral fractures under a Japanese incentive policy

BACKGROUND

Proximal femoral fractures in geriatric patients are a major challenge in orthopedics, often leading to major functional impairment. Early surgical intervention is crucial for improving patient recovery and overall health outcomes. Thus, Japan's Ministry of Health, Labour and Welfare initiated a reimbursement policy in April 2022 to encourage early surgery for these fractures in patients aged ≥75 years. This study investigated the impact of this policy on early surgery rates in Japan and identified factors influencing the timing of surgical interventions.

METHODS

We retrospectively analyzed the data of patients who underwent surgery for proximal femoral fractures at our institution between April 2022 and March 2023. Patients were categorized into two groups based on the timing of surgery relative to the injury: ≤48 h and >48 h. Demographic and clinical data, including age, sex, fracture type, and various health- and admission-related factors, were assessed.

RESULTS

Of the 192 patients, 152 were included in the study. Among them, 38% underwent early surgery (≤48 h), and 15% of the patients arrived more than 48 h post-injury. Significant differences were found in admission routes and residence types between the groups. The ≤48 h group had shorter intervals from injury to admission and surgery than the >48 h group. Factors such as the admission process, day of the week, and C-reactive protein levels significantly influenced the timing of surgery.

CONCLUSIONS

After introducing incentives for early surgery in Japan, 38% of patients with proximal femoral fractures underwent surgery within 48 h of injury. Factors contributing to patients not receiving early surgery included transport from another hospital, weekend hospitalization, and elevated CRP levels. These findings suggest that achieving surgery within 48 h of injury is challenging through hospital efforts alone, and the time criteria might be more appropriate if changed to "admission to surgery."

Seasonal patterns of hip fracture incidence and mortality rates across age groups of older adults in Israel

PURPOSE

This study investigates the seasonal patterns of hip fracture occurrence and mortality rates in the elderly population of Israel.

METHODS

In this retrospective study, we examined a random sample of 400 patients who underwent a hip fracture repair surgery at a 495-bed hospital in northern-central Israel during the years 2021-2022.

RESULTS

Our findings reveal a heightened incidence of hip fractures during the spring (30.8%) in contrast to relatively consistent rates during other seasons (22-24.2%). Patients experiencing hip fractures in the spring were notably younger and had shorter hospital stays compared to those in other seasons. Furthermore, we identified seasonal variations in hip fracture incidence concerning gender, culture, and nationality. Over the 2-year follow-up period, 20% of patients had succumbed to mortality. The highest survival rate was associated with hip fractures sustained in the spring, while the lowest rates were observed in the autumn and winter.

CONCLUSION

While our study highlights significant seasonal variations in hip fracture occurrence and mortality rates among the elderly population in Israel, caution is warranted in interpreting the implications for post-fracture care and resource allocation. The observed heightened incidence of hip fractures during the spring, particularly among younger patients with shorter hospital stays, suggests the need for further investigation into potential risk factors and preventive measures specific to this season. Additionally, our identification of seasonal variations in hip fracture incidence across demographic factors underscores the importance of tailored interventions to address the diverse needs of different populations.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study

BACKGROUND

Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries.

METHODS

We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery.

RESULTS

The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada).

CONCLUSIONS

We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

Incidence and number of fragility fractures of the hip in South Africa: estimated projections from 2020 to 2050

Sub-Saharan Africa is undergoing rapid population ageing and better understanding of the burden of musculoskeletal conditions is needed. We have estimated a large increase in the burden of hip fractures for South Africa over the coming decades. These findings should support preparation of hip fracture services to meet this demand.

INTRODUCTION

A better understanding of the burden of fragility fractures in sub-Saharan Africa is needed to inform healthcare planning. We aimed to use recent hip fracture incidence data from South Africa (SA) to estimate the future burden of hip fracture for the country over the next three decades.

METHODS

Hip fracture incidence data within the Gauteng, KwaZulu-Natal and Western Cape provinces of SA were obtained from patients aged ≥ 40 years with a radiograph-confirmed hip fracture in one of 94 included hospitals. Age-, sex- and ethnicity-specific incidence rates were generated using the 2011 SA census population for the study areas. Incidence rates were standardised to United Nations (UN) population projections, for the years 2020, 2030, 2040 and 2050, and absolute numbers of hip fractures derived.

RESULTS

The 2767 hip fracture patients studied had mean (SD) age 73.7 (12.7) years; 69% were female. Estimated age- and ethnicity-standardised incidence rates (per 100,000 person-years) for the overall SA population in 2020 were 81.2 for females and 43.1 for males. Overall projected incidence rates were discernibly higher by the year 2040 and increased further by the year 2050 (109.0 and 54.1 for females and males, respectively). Estimates of the overall annual number of hip fractures for SA increased from approximately 11,000 in 2020 to approximately 26,400 by 2050.

CONCLUSION

The hip fracture burden for SA is expected to more than double over the next 30 years. Significant investment in fracture prevention services and inpatient fracture care is likely to be needed to meet this demand.

Reasons for Surgical Delay in Patients With Hip Fracture

INTRODUCTION

15% of patients with hip fracture older than 65 years in Israel have delayed surgery. The aim of this study was to determine which patient and/or organizational factors are associated with a delay of beyond 48 hours in hip fracture repair surgery.

METHODS

A retrospective cohort study of 281 patients with hip fracture who underwent surgery during 2019-2020. Characteristics of patients with early surgery (n = 40) and patients with delayed surgery (n = 241) were compared.

RESULTS

Presence of a cardiac disease (odds ratio [OR] = 1.38), pulmonary disease (OR = 1.21), or obesity (OR = 1.18) was identified as risk factors for surgical delay. Each additional comorbidity increased the risk. Most of the documented reasons for delay were medical, with antiplatelet therapy the most common (n = 8, 20%). Unavailable operating rooms were another common reason for delays (n = 8, 20%). In addition, a higher percentage of patients with delayed surgery were admitted in August and September (42.5%).

CONCLUSIONS

It seems that most delays were for medical reasons. However, it is unclear whether allegedly clinically justified delays were indeed of benefit to the patients. Health care organizations should strive to minimize the impact of organizational factors on surgical delay.

Access to care for low trauma hip fractures in South Africa

RATIONALE

Early surgery is recommended for hip fractures.

MAIN RESULT

In this study only one-third of subjects with hip fractures were admitted within 24 h of the fracture, and surgery was delayed beyond 48 h in the majority.

SIGNIFICANCE

These findings highlight the need to improve access to care for hip fracture subjects.

PURPOSE

There is limited data on the timing of admission and surgery following a low trauma hip fracture (HF) in South Africa (SA).

METHODS

A prospective, observational study was conducted at public and private hospitals in three provinces, Gauteng (GP), KwaZulu-Natal (KZN) and the Western Cape (WC), in SA to determine time from fracture to admission and from admission to surgery in patients presenting with low trauma HF. Associations with delayed admission and surgery were explored using logistic regression.

RESULTS

The median age of the 1996 subjects was 73 years (IQR 63-81 years), the majority were women (1346, 67%) and 1347 (67%) were admitted to the public hospitals. In one-third of subjects (661, 33%), admission was delayed to beyond 24 h after the fracture. There was a significantly longer time to admission in public compared to private hospitals (21 h [IQR 10.0-48.5] versus 6 h [IQR 3.3-14.1], p < 0.001), in subjects < 65 years, the WC and when admission occurred on a weekday. Surgery was delayed beyond 48 h in the majority (1272, 69%) of subjects and was significantly longer in public compared to private hospitals (130 h [IQR 62.6-212.4] versus 45.4 h [IQR 24.0-75.5], p < 0.001), in KZN, and when admission occurred after hours.

CONCLUSION

The burden of HFs is higher at public hospitals in SA, where there is a significant delay in admission after a fracture and surgery after admission. This highlights the need for a review of HF care pathways, resources and policies.

Mortality incidence and its determinants after fragility hip fractures: a prospective cohort study from an Egyptian level one trauma center

Background

Fragility hip fracture is a common condition with serious consequences. Most outcomes data come from Western and Asian populations. There are few data from African and Middle Eastern countries.

Objective

The primary objective was to describe mortality rates after fragility hip fracture in a Level-1 trauma centre in Egypt. The secondary objective was to study the causes of re-admissions, complications, and mortality.

Methods

A prospective cohort study of 301 patients, aged > 65 years, with fragility hip fractures. Data collected included sociodemographic, co-morbidities, timing of admission, and intraoperative,ostoperative, and post-discharge data as mortality, complications, hospital stay, reoperation, and re-admission. Cox regression analysis was conducted to investigate factors associated with 1-year mortality.

Results

In-hospital mortality was 8.3% (25 patients) which increased to 52.8% (159 patients) after one year; 58.5% of the deaths occurred in the first 3-months. One-year mortality was independently associated with increasing age, ASA 3–4, cardiac or hepatic co-morbidities, trochanteric fractures, total hospital stay, and postoperative ifection and metal failure.

Conclusion

Our in-hospital mortality rate resembles developed countries reports, reflecting good initial geriatric healthcare. However, our 3- and 12-months mortality rates are unexpectedly high. The implementation of orthogeriatric care after discharge is mandatory to decrease mortality rates.