Prediction of postoperative mortality in elderly patient with hip fractures: a single-centre, retrospective cohort study

Admission Inflammation Markers Influence Long-term Mortality in Elderly Patients Undergoing Hip Fracture Surgery: A Retrospective Cohort Study

OBJECTIVES

Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that some inflammation biomarkers may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission inflammation biomarkers in elderly patients with hip fracture.

METHODS

We reports on a retrospective study of elderly hip fracture patients admitted to a hospital in China between January 2015 and December 2019. A total of 1085 patients were included in the study, and their demographic and pre-operative characteristics were analyzed. The inflammation biomarkers included monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), and C-reactive protein (CRP) to albumin ratio (CAR). The predictive performance of NLR, MLR and CAR was assessed by receiver operating characteristics (ROC) curve analysis and the association between admission inflammation markers and mortality was evaluated by Cox proportional regression.

RESULTS

The 30-day, 1-year, 2-year, and 4-year mortality were 1.6%, 11.5%, 21.4% and 48.9%, respectively. The optimal cut-off values of admission NLR, MLR and CAR for 1-year mortality were 7.28, 0.76, and 1.36. After adjusting the covariates, preoperative NLR ≥ 7.28 (HR = 1.419, 95% CI: 1.080-1.864, p = 0.012) were found to be only independent risk factors with 4-year all-cause mortality, the preoperative CAR ≥ 1.36 was independently associated with 1-year (HR = 1.700, 95% CI: 1.173-2.465, p = 0.005), 2 year (HR = 1.464, 95% CI: 1.107-1.936, p = 0.008), and 4-year (HR = 1.341, 95% CI: 1.057-1.700, p = 0.016) all-cause mortality, While age, CCI score, and low hemoglobin at admission were also risk factors for postoperative all-cause mortality.

CONCLUSION

Admission CAR and NLR may be useful indicators for predicting the long-term mortality of elderly patients undergoing hip fracture surgery, and that more research is needed to validate these findings.

Inflammatory Index as a Predictor of Mortality in Elderly Patients With Intracapsular Femoral Neck Fracture

A femoral neck fracture is a major cause of mortality in the elderly population, and intracapsular femoral neck fractures (ICFNFs) are commonly treated with hemiarthroplasty. The 30-day mortality rate for elderly hip fracture patients ranges from 1.0% to 6.5%, and one-year mortality increases significantly to 37.3%. Identifying predictors of mortality in these patients is crucial for better management. Inflammatory indices, such as neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and monocyte-to-lymphocyte ratio (MLR), have gained popularity for assessing mortality risk in various diseases. Several studies have demonstrated the value of these indices in predicting mortality after hip fracture. The pan-inflammatory immune value (PIV), which combines hematological parameters, has been shown to predict mortality in cancer patients. However, its role in predicting mortality in ICFNF patients treated with hemiarthroplasty has yet to be explored. This study aimed to assess the association of PIV, SII, NLR, and MLR with 30-day and one-year mortality in ICFNF patients. We also investigated the impact of surgical delay time (≤24h, 24-48h, ≥48h) on these inflammatory indices and mortality. Data from 522 patients with ICFNF treated with hemiarthroplasty were retrospectively collected. We observed 30-day and one-year mortality rates of 5.24% and 21.2%, respectively. Age, gender, and American Society of Anesthesiologists (ASA) score were identified as significant predictors of mortality. Preoperative PIV, SII, NLR, and MLR were significant predictors in the evaluation of early mortality. However, postoperatively, only NLR on the third day (NLR3rd) demonstrated statistical significance. Stepwise logistic regression further confirmed NLR3rd as the most effective predictor for early mortality. For mortality occurring between 30 to 365 days, NLR3rd remained statistically significant, albeit with diminished sensitivity. No other inflammatory index demonstrated significant predictive power for mortality during this later period. Our findings suggest different inflammatory indices may have varying predictive abilities depending on the mortality period. We recommend considering NLR3rd as a valuable and reliable predictor for early mortality in ICFNF patients treated with hemiarthroplasty. Respiratory system disease and preoperative chronic obstructive pulmonary disease (COPD) were identified as risk factors for mortality in our study, in line with previous research. In conclusion, our study highlights the potential of specific inflammatory indexes, particularly NLR3rd, in predicting mortality in elderly patients with ICFNFs treated with hemiarthroplasty. Further research is needed to validate these findings and optimize risk assessment in orthopedic practice.

Predictive Value of the C-Reactive Protein to Albumin Ratio in 30-Day Mortality after Hip Fracture in Elderly Population: A Retrospective Observational Cohort Study

BACKGROUND

C-reactive protein (CRP) to Albumin ratio (CAR) has been used in multiple clinical settings to predict early mortality. However, there is a lack of evidence on the predictive role of CAR in 30-day mortality after a hip fracture. The purpose of this study was to establish a potential association between CAR and 30-day mortality and to assess if the CAR Receiving Operating Characteristics curve (ROC) can be a reliable predictor of early mortality.

METHODS

We retrospectively reviewed the charts of 676 patients (>65 years) treated for hip fracture between 2006 and 2018. All hip fractures were included. Treatment strategies included closed reduction and internal fixation, open reduction and internal fixation, hemiarthroplasty, or total joint arthroplasty. Statistical analysis included T-test, Pearson correlation for CAR and other markers, ROC curves and area under the curve, Youden Model, and Odds Ratio.

RESULTS

The 30-day mortality rate analysis showed that higher preoperative levels of CAR were associated with higher early mortality. When analyzing the area under the ROC curve (AUROC) for 30-day mortality, the reported value was 0.816. The point of the ROC curve corresponding to 14.72 was considered a cut-off with a specificity of 87% and a sensibility of 40.8%. When analyzing values higher than 14.72, the 30-day mortality rate was 17.9%, whilst, for values lower than 14.72, the 30-day mortality rate was 1.8%.

CONCLUSIONS

Patients older than 65 years affected by a hip fracture with increased preoperative levels of CAR are associated with higher 30-day mortality. Despite a moderate sensibility, considering the low cost and the predictivity of CAR, it should be considered a standard predictive marker.

Predictability of Neutrophil to Lymphocyte Ratio in preoperative elderly hip fracture patients for post-operative short-term complications: a retrospective study

PURPOSE

Neutrophil to Lymphocyte Ratio (NLR) is a simple biomarker of systemic inflammatory response. We investigated predictability of NLR for early adverse outcome after surgery for hip fracture in elderly population.

METHODS

We reviewed a total of 971 elderly patients with hip fracture who underwent emergency surgery between January 2017 and July 2020 in the Department of Orthopaedics Surgery at the Wollongong Hospital. After considering exclusion criteria, data from a total of 834 patients included in our study. Socio-demographic data, NLR in admission, updated Charlson comorbidity index (uCCI), biochemical markers, mortality rate and 15 short term post-operative complications were collected to determine predictability of NLR for post-operative complications and mortality.

RESULTS

After hip surgery, Hospital in-patient case fatality rate was 3.7% (31). In addition, 63.1% (511) of the patients had at least one complication or more. Logistic regression demonstrated that raised NLR (P-value < 0.001, OR 1.05) and uCCI≥4 (P-Value < 0.001, OR 1.75) are associated with post-operative complications. Moreover, decreased haemoglobin was associated with adverse effects (P-value < 0.001, OR 0.97). No association was found for any of these variables with in-patient mortality except for albumin (P-value: 0.03). In addition, despite significant association, ROC analyses showed a low predictability for each of the above variables including NLR (AUC 0.59) for post-operative complications.

CONCLUSIONS

Despite significant association, NLR was unable to prognosticate early adverse outcomes. However, it can be considered as a risk factor in admission for postoperative complications in combination with other risk factors and clinical context.

Correlation between C-reactive protein and postoperative mortality in patients undergoing hip fracture surgery: a meta-analysis

BACKGROUND

Hip fracture is a common but devastating disease with a high mortality rate in the older adult population. C-reactive protein (CRP) is a predictor of the prognosis in many diseases, but its correlations with patient outcomes following hip fracture surgery remain unclear. In this meta-analysis, we investigated the correlation between perioperative CRP level and postoperative mortality in patients undergoing hip fracture surgery.

METHODS

PubMed, Embase, and Scopus were searched for relevant studies published before September 2022. Observational studies investigating the correlation between perioperative CRP level and postoperative mortality in patients with hip fracture were included. The differences in CRP levels between the survivors and nonsurvivors following hip fracture surgery were measured with mean differences (MDs) and 95% confidence intervals (CIs).

RESULTS

Fourteen prospective and retrospective cohort studies comprising 3986 patients with hip fracture were included in the meta-analysis. Both the preoperative and postoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≥ 6 months (MD: 0.67, 95% CI: 0.37-0.98, P < 0.0001; MD: 1.26, 95% CI: 0.87-1.65, P < 0.00001, respectively). Preoperative CRP levels were significantly higher in the death group than in the survival group when the follow-up duration was ≤ 30 days (MD: 1.49, 95% CI: 0.29-2.68; P = 0.01).

CONCLUSIONS

Both higher preoperative and postoperative CRP levels were correlated with higher risk of mortality following hip fracture surgery, suggesting the prognostic role of CRP. Further studies are warranted to confirm the ability of CRP to predict postoperative mortality in patients with hip fracture.

Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture

Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.

Can C-reactive protein-based biomarkers be used as predictive of 30-day mortality in elderly hip fractures?A retrospective study

BACKGROUND

C-reactive protein-to-lymphocyte ratio (CLR), C-reactive protein/albumin (CRP/ALB), and CRP are prognostic factors for outcome and survival in oncology and digestive surgery. CLR has not been studied for the prediction of mortality in hip fracture. The aim of this study is to investigate whether there is an association between pre-operative CLR, CRP/ALB, and CRP levels in patients with hip fracture and patient survival.

METHODS

The medical reports of the patients who underwent surgery with a diagnosis of hip fracture in our hospital between January 2016 and December 2019 were retrospectively reviewed. The patients were divided into two groups (Group E: Those who died within 1 month and Group S: Those who died after the 1st month or those who survived). A total of 19 parameters, namely, included ' blood parameters including hemoglobin, C-reactive protein, albumin, lymphocytes, neutrophils, monocytes, platelets, PLR, NLR, LMR, CLR CRP/ALB ratios, gender, American Society of Anesthesiologists, Charlson Comorbidity Index, delirium, infections, repeated surgeries, and type of anesthesia were evaluated preoperatively and on the post-operative 2nd and 5th days and 1 month.

RESULTS

A total of 165 patients with the mean age of 83.09±8.52 years who met the inclusion criteria were studied. The pre-op-erative means of CRP, neutrophil count, CLR ratio, and CRP/ALB ratio were statistically significantly higher in Group E than in Group S (p=0.016, p=0.023, p=0.035, and p=0.044, respectively). The univariate regression analysis showed that age, pre-operative Hb level, CRP, and CRP/ALB ratio were significant predictors of the 1-month mortality (ß=-0.335, p=0.049; ß=0.411, p=0.028; ß=3.632, p=0.007; and ß=-3.280, p=0.008; respectively). When we performed the ROC curve analysis, the CRP/ALB ratio had the highest AUC, with the highest sensitivity and specificity. The cutoff value of CRP/ALB ratio was found to be 12.42.

CONCLUSION

We found that the pre-operative CRP/ALB ratio is an important parameter for predicting the first 30-day mortality in elderly patients with intertrochanteric femur fractures. For this reason, we recommend that CRP and albumin be checked in prepa-ration for routine pre-operative anesthesia.

Validation of the PreOperative Score to predict Post-Operative Mortality (POSPOM) in Dutch non-cardiac surgery patients

Background

Standardized risk assessment tools can be used to identify patients at higher risk for postoperative complications and death. In this study, we validate the PreOperative Score to predict Post-Operative Mortality (POSPOM) for in-hospital mortality in a large cohort of non-cardiac surgery patients. In addition, the performance of POSPOM to predict postoperative complications was studied.

Methods

Data from the control cohort of the TRACE (routine posTsuRgical Anesthesia visit to improve patient outComE) study was analysed. POSPOM scores for each patient were calculated post-hoc. Observed in-hospital mortality was compared with predicted mortality according to POSPOM. Discrimination was assessed by receiver operating characteristic curves with C-statistics for in-hospital mortality and postoperative complications. To describe the performance of POSPOM sensitivity, specificity, negative predictive values, and positive predictive values were calculated. For in-hospital mortality, calibration was assessed by a calibration plot.

Results

In 2490 patients, the observed in-hospital mortality was 0.5%, compared to 1.3% as predicted by POSPOM. 27.1% of patients had at least one postoperative complication of which 22.4% had a major complication. For in-hospital mortality, POSPOM showed strong discrimination with a C-statistic of 0.86 (95% CI, 0.78–0.93). For the prediction of complications, the discrimination was poor to fair depending on the severity of the complication. The calibration plot showed poor calibration of POSPOM with an overestimation of in-hospital mortality.

Conclusion

Despite the strong discriminatory performance, POSPOM showed poor calibration with an overestimation of in-hospital mortality. Performance of POSPOM for the prediction of any postoperative complication was poor but improved according to severity.

Development of a prognostic model for 1-year survival after fragile hip fracture in Chinese

Background

No prognostic model for the survival of fragile hip fracture has been developed for Asians. The goal of this study was to develop a simple and practical prognostic model to predict survival within 1 year after fragile hip fracture in Asians.

Methods

A single-center retrospective cohort study was designed. Under a multivariable Cox proportional hazards regression model, we used the preoperative characteristics of patients to predict survival within 1 year after hip fracture. We built a full model and then used the least absolute shrinkage and selection operator (LASSO) method to further shrink the model coefficients and achieved variable screening. Finally, we obtained a LASSO model. The model performance was evaluated with Nagelkerke’s R² and the concordance (c) statistic. We assessed the internal validity with a bootstrapping procedure of 1 000 repetitions.

Results

A total of 735 eligible patients were admitted to our department for hip fracture from January 2015 to December 2020, but 11 (1.5%) patients were lost to follow-up. Among the remaining patients, 68 (9.3%) died within 1 year after hip fracture. We identified 12 candidate predictors from the preoperative characteristics of the patients. The last model contained nine predictors: surgery, age, albumin, sex, serum creatinine, malignancy, hypertension, ability to live independently, and cardiovascular and cerebrovascular diseases. Among them, surgery, age, and albumin are effective predictors of survival. The discrimination c statistic of the model is 0.814 (95% confidence interval 0.762–0.865); the corrected value through internal validation is 0.795.

Conclusions

This prognostic model can accurately predict a 1-year survival rate for patients with fragile hip fractures. This information can help clinicians develop a reasonable and personalized treatment plan.

Correlation between neutrophil-to-lymphocyte ratio and postoperative mortality in elderly patients with hip fracture: a meta-analysis

Introduction

The neutrophil-to-lymphocyte ratio (NLR) is a crucial prognosis predictor following several major operations. However, the association between NLR and the outcome after hip fracture surgery is unclear. In this meta-analysis, we investigated the correlation between NLR and postoperative mortality in geriatric patients following hip surgery.

Method

PubMed, Embase, Cochrane library, and Google Scholar were searched for studies up to June 2021 reporting the correlation between NLR and postoperative mortality in elderly patients undergoing surgery for hip fracture. Data from studies reporting the mean of NLR and its 95% confidence interval (CI) were pooled. Both long-term (≥ 1 year) and short-term (≤ 30 days) mortality rates were included for analysis.

Result

Eight retrospective studies comprising a total of 1563 patients were included. Both preoperative and postoperative NLRs (mean difference [MD]: 2.75, 95% CI: 0.23–5.27; P = 0.03 and MD: 2.36, 95% CI: 0.51–4.21; P = 0.01, respectively) were significantly higher in the long-term mortality group than in the long-term survival group. However, no significant differences in NLR were noted between the short-term mortality and survival groups (MD: − 1.02, 95% CI: − 3.98 to 1.93; P = 0.5).

Conclusion

Higher preoperative and postoperative NLRs were correlated with a higher risk of long-term mortality following surgery for hip fracture in the geriatric population, suggesting the prognostic value of NLR for long-term survival. Further studies with well-controlled confounders are warranted to clarify the predictive value of NLR in clinical practice in geriatric patients with hip fracture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02831-6.

The level of postoperative care influences mortality prediction by the POSPOM score: A retrospective cohort analysis

BACKGROUND

The Preoperative Score to Predict Postoperative Mortality (POSPOM) assesses the patients' individual risk for postsurgical intrahospital death based on preoperative parameters. We hypothesized that mortality predicted by the POSPOM varies depending on the level of postoperative care.

METHODS

All patients age over 18 years undergoing inpatient surgery or interventions involving anesthesia at a German university hospital between January 2006, and December 2017, were assessed for eligibility for this retrospective study. Endpoint was death in hospital following surgery. Adaptation of the POSPOM to the German coding system was performed as previously described. The whole cohort was divided according to the level of postoperative care (normal ward vs. intensive care unit (ICU) admission within 24 h vs. later than 24 h, respectively).

RESULTS

199,258 patients were finally included. Observed intrahospital mortality was 2.0% (4,053 deaths). 9.6% of patients were transferred to ICU following surgery, and mortality of those patients was increased already at low POSPOM values of 15. 17,165 patients were admitted to ICU within 24 h, and these patients were older, had more comorbidities, or underwent more invasive surgery, reflected by a higher median POSPOM score compared to the normal-ward group (29 vs. 17, p <0.001). Mortality in that cohort was significantly increased to 8.7% (p <0.001). 2,043 patients were admitted to ICU later than 24 h following surgery (therefore denoted unscheduled admission), and the median POSPOM value of that group was 23. Observed mortality in this cohort was highest (13.5%, p <0.001 vs. ICU admission <24 h cohort).

CONCLUSION

Increased mortality in patients transferred to high-care wards reflects the significance of, e.g., intra- or early postoperative events for the patients' outcome. Therefore, scoring systems considering only preoperative variables such as the POSPOM reveal limitations to predict the individual benefit of postoperative ICU admission.

Validation of Neutrophil-to-Lymphocyte Ratio Cut-off Value Associated with High In-Hospital Mortality in COVID-19 Patients

Introduction

The neutrophil-to-lymphocyte ratio (NLR) could be a predictive factor of severe COVID-19. However, most relevant studies are retrospective, and the optimal NLR cut-off point has not been determined. The objective of our research was identification and validation of the best NLR cut-off value on admission that could predict high in-hospital mortality in COVID-19 patients.

Methods

Medical files of all patients admitted for COVID-19 pneumonia in our dedicated COVID-units between March and April 2020 (derivation cohort) and between October and December 2020 (validation cohort) were reviewed.

Results

Two hundred ninety-nine patients were included in the study (198 in the derivation and 101 in the validation cohort, respectively). Youden’s J statistic in the derivation cohort determined the optimal cut-off value for the performance of NLR at admission to predict mortality in hospitalized patients with COVID-19. The NLR cut-off value of 5.94 had a sensitivity of 62% and specificity of 64%. In ROC curve analysis, the AUC was 0.665 [95% CI 0.530–0.801, p= 0.025]. In the validation cohort, the best predictive cut-off value of NLR was 6.4, which corresponded to a sensitivity of 63% and a specificity of 64% with AUC 0.766 [95% CI 0.651–0.881, p <0.001]. When the NLR cut-off value of 5.94 was applied in the validation cohort, there was no significant difference in death and survival in comparison with the derivation NLR cut-off. Net reclassification improvement (NRI) analysis showed no significant classification change in outcome between both NLR cut-off values (NRI:0.012, p=0.31).

Conclusion

In prospective analysis, an NLR value of 5.94 predicted high in-hospital mortality upon admission in patients hospitalized for COVID-19 pneumonia.

Predictive factors associated with the clinical outcome of intertrochanteric hip fracture in high-risk elderly patients treated with total hip arthroplasty versus percutaneous external fixation

Background

Little is known regarding the survival and functional recovery of elderly intertrochanteric hip fracture (IHF) patients after total hip arthroplasty (THA) versus percutaneous external fixation (PEF). This study aims to analyze the prognostic factors of THA and PEF in elderly IHF patients.

Methods

A total of 155 consecutive elderly patients (mean age of 80 years) diagnosed with IHF were retrospectively reviewed from our database between January 1, 2010, and December 31, 2018. The preoperative, intraoperative and postoperative covariates were analyzed by two independent surgical cohorts: THA and PEF. The main outcomes included the hip function score, all-cause mortality within 1 year after surgery, and overall survival. Covariables and their influence on independent outcomes were analyzed using multivariate regression models.

Results

The median follow-up period was 5.1 years, and 6 patients were lost to follow-up. At the endpoint, 70 of 85 patients treated with THA and 37 of 70 patients treated with PEF survived, exhibiting mean Harris hip scores of 84.4 and 69.0, respectively. The Kaplan-Meier curves and log-rank tests showed no significant difference in overall survival. After adjusting for the covariates, the surgical mode was a unique prognostic factor affecting hip function recovery, and two prognostic factors (leukocyte count and D-dimer) were correlated with 1-year all-cause mortality. Age at admission, fracture classification, D-dimer level and surgical mode were identified as prognostic factors affecting overall survival. After adjusting for the former three covariates, THA reduced the risk of death by 67.20% compared with PEF (HR 0.328, 95% CI, 0.121–0.890).

Conclusions

Despite the nonsignificant difference in 1-year all-cause mortality, THA demonstrated superior midterm survival and hip function recovery in elderly IHF patients compared with PEF. Predictive factors, including age at admission, fracture classification, D-dimer level and surgical mode, are associated with the overall survival of IHF in high-risk elderly patients.

Validation of the Preoperative Score to Predict Postoperative Mortality (POSPOM) in Germany

BACKGROUND

The Preoperative Score to Predict Postoperative Mortality (POSPOM) based on preoperatively available data was presented by Le Manach et al. in 2016. This prognostic model considers the kind of surgical procedure, patients' age and 15 defined comorbidities to predict the risk of postoperative in-hospital mortality. Objective of the present study was to validate POSPOM for the German healthcare coding system (G-POSPOM).

METHODS AND FINDINGS

All cases involving anaesthesia performed at the University Hospital Bonn between 2006 and 2017 were analysed retrospectively. Procedures codified according to the French Groupes Homogènes de Malades (GHM) were translated and adapted to the German Operationen- und Prozedurenschlüssel (OPS). Comorbidities were identified by the documented International Statistical Classification of Diseases (ICD-10) coding. POSPOM was calculated for the analysed patient collective using these data according to the method described by Le Manach et al. Performance of thereby adapted POSPOM was tested using c-statistic, Brier score and a calibration plot. Validation was performed using data from 199,780 surgical cases. With a mean age of 56.33 years (SD 18.59) and a proportion of 49.24% females, the overall cohort had a mean POSPOM value of 18.18 (SD 8.11). There were 4,066 in-hospital deaths, corresponding to an in-hospital mortality rate of 2.04% (95% CI 1.97 to 2.09%) in our sample. POSPOM showed a good performance with a c-statistic of 0.771 and a Brier score of 0.021.

CONCLUSIONS

After adapting POSPOM to the German coding system, we were able to validate the score using patient data of a German university hospital. According to previous demonstration for French patient cohorts, we observed a good correlation of POSPOM with in-hospital mortality. Therefore, further adjustments of POSPOM considering also multicentre and transnational validation should be pursued based on this proof of concept.