Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study

A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients

INTRODUCTION

Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients.

METHODS

This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum.

RESULTS

A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum.

CONCLUSION

Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality

PURPOSE

Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.

METHODS

All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS ≥ 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.

RESULTS

After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].

CONCLUSION

Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

Background

Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses.

Methods

This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders.

Results

A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia.

Conclusions

Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups.

Level of evidence: Therapeutic/Care Management, level III

Factors associated with functional disability or mortality after elective noncardiac surgery: a prospective cohort study

PURPOSE

Preoperative prediction of functional status after surgery is essential when practicing patient-centered medicine. We aimed to evaluate the incidence and factors associated with postoperative functional disability or all-cause mortality. Secondarily, we sought to describe the trajectory of disability in this population.

METHODS

Adults aged ≥ 55 yr who underwent elective noncardiac surgery under general anesthesia in a tertiary care hospital were followed up one year after surgery. Pre- and intraoperative factors associated with a composite outcome of postoperative functional disability or all-cause mortality were assessed using a multiple logistic regression. The sequential changes in the 12-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 score were described and stratified by surgical invasiveness.

RESULTS

Of the 2,921 patients included, 293 experienced postoperative functional disability (10.0%; 95% confidence interval [CI], 8.9 to 11.1) and 124 died (4.2%; 95% CI, 3.5 to 5.0). In a multiple regression model, the potentially modifiable risk factors, body mass index ≥ 30 kg·m-2 and poor preoperative nutritional status, were significantly associated with the primary composite outcome, as well as nonmodifiable factors such as age, preoperative comorbidities, and blood loss volume. Changes in the 12-item WHODAS 2.0 disability score varied between different levels of surgical invasiveness and types of surgery.

CONCLUSION

Within one year after surgery, one in ten patients experienced postoperative functional disability and one in 20 died. We identified potentially modifiable factors (obesity, poor nutritional status) associated with these adverse outcomes.

STUDY REGISTRATION

University Hospital Medical Information Network (UMIN000021671); registered 31 December 2015.

Dementia is a surrogate for frailty in hip fracture mortality prediction

Purpose

Among hip fracture patients both dementia and frailty are particularly prevalent. The aim of the current study was to determine if dementia functions as a surrogate for frailty, or if it confers additional information as a comorbidity when predicting postoperative mortality after a hip fracture.

Methods

All adult patients who suffered a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017 were considered for inclusion. Pathological fractures, non-operatively treated fractures, reoperations, and patients missing data were excluded. Logistic regression (LR) models were fitted, one including and one excluding measurements of frailty, with postoperative mortality as the response variable. The primary outcome of interest was 30-day postoperative mortality. The relative importance for all variables was determined using the permutation importance. New LR models were constructed using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

Results

121,305 patients were included in the study. Initially, dementia was among the top ten most important variables for predicting 30-day mortality. When measurements of frailty were included, dementia was replaced in relative importance by the ability to walk alone outdoors and institutionalization. There was no significant difference in the predictive ability of the models fitted using the top ten most important variables when comparing those that included [AUC for 30-day mortality (95% CI): 0.82 (0.81–0.82)] and excluded [AUC for 30-day mortality (95% CI): 0.81 (0.80–0.81)] measurements of frailty.

Conclusion

Dementia functions as a surrogate for frailty when predicting mortality up to one year after hip fracture surgery. The presence of dementia in a patient without frailty does not appreciably contribute to the prediction of postoperative mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01960-9.