In-hospital mortality after hip fracture by treatment setting

Naïve Bayes is an interpretable and predictive machine learning algorithm in predicting osteoporotic hip fracture in-hospital mortality compared to other machine learning algorithms

Osteoporotic hip fractures (HFs) in the elderly are a pertinent issue in healthcare, particularly in developed countries such as Australia. Estimating prognosis following admission remains a key challenge. Current predictive tools require numerous patient input features including those unavailable early in admission. Moreover, attempts to explain machine learning [ML]-based predictions are lacking. Seven ML prognostication models were developed to predict in-hospital mortality following minimal trauma HF in those aged ≥ 65 years of age, requiring only sociodemographic and comorbidity data as input. Hyperparameter tuning was performed via fractional factorial design of experiments combined with grid search; models were evaluated with 5-fold cross-validation and area under the receiver operating characteristic curve (AUROC). For explainability, ML models were directly interpreted as well as analysed with SHAP values. Top performing models were random forests, naïve Bayes [NB], extreme gradient boosting, and logistic regression (AUROCs ranging 0.682-0.696, p>0.05). Interpretation of models found the most important features were chronic kidney disease, cardiovascular comorbidities and markers of bone metabolism; NB also offers direct intuitive interpretation. Overall, NB has much potential as an algorithm, due to its simplicity and interpretability whilst maintaining competitive predictive performance.

Health Outcomes of Older Adults after a Hospitalization for a Hip Fracture

Background

Hip fractures in older adults often lead to adverse health outcomes, which may be related to time to surgery and longer hospital stays. The experience of older adults with hip fractures in New Brunswick is not known.

Methods

This was a retrospective observational study. All hip fracture patients 65 years of age and older admitted to one hospital designated as a Level One Trauma Centre between April 1, 2015 and March 31, 2019 comprised the sample.

Results

The majority (86.5%) received surgery within 48 hours and those who had surgery beyond this time frame had a significantly longer stay in acute care (OR: 3.79, 95% CI: 2.05-7.15). The mean total length of stay (Total-LOS) for patients discharged after their acute care needs were met was 9.8 days (SD=8.1) compared to patients experiencing delays in discharge for nonmedical reasons which was 26.3 days (SD=33.7). An extended stay in acute care (OR: 1.93, 95% CI: 1.09-3.43) and increasing age (OR: 1.03, 95% CI: 1.001-1.06) were associated with a higher likelihood of death at one year post-discharge. Time to surgery beyond 24 hours (OR: 2.80, 95% CI: 1.13-7.38) was associated with a higher likelihood of death 30 days post-discharge.

Conclusions

Most patients had surgery within the national benchmark of less than 48 hours. The Total-LOS increased 2.5-fold in patients who remained in hospital after their acute care needs were met. A better understanding of patient characteristics, such as frailty, may better predict patients at risk for longer hospital stays and adverse health outcomes.

Risk Factors for Prolonged Hospital Stay After Femoral Neck Fracture

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64-98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211-217.].

Time to Hip Fracture Surgery and Mortality

OBJECTIVE

This retrospective study explored the impact of time to surgery in acute hip fractures and outcomes in patients with acute hip fractures at a level I trauma center within an academic medical center in the southeastern United States. The objective was to explore the association between time to surgery and 30-day mortality and outcomes in adults 65 years and older undergoing hip fracture surgery for traumatic injuries in 2014-2019.

METHODS

The population of this study consisted of patients who presented with a hip fracture and required operative measures. The research team conducted a secondary data analysis of medical records among patients who experienced a hip fracture and subsequent hip surgery to address the injury.

RESULTS

Results from this study demonstrated a statistically significant relationship between a delay in surgery and an increase in postoperative complications and morbidity, as well as increased morbidity among male patients.

CONCLUSIONS

Incidence of hip fractures is increasing among older adult patients and is cause for concern because of an associated high mortality rate and risk of postoperative complications. The existing body of literature indicates earlier surgical intervention may improve outcomes and reduce postoperative complications and mortality. The results of this study affirm these findings and suggest further examination specifically among males.

Association between cigarette smoking and mortality in patients with hip fracture: A systematic review and meta-analysis

INTRODUCTION

Hip fracture is associated with substantial morbidity and mortality, especially among the elderly. Current evidence on the association between cigarette smoking and mortality in hip-fracture patients is controversial. We performed a systematic review and meta-analysis of studies on this association.

METHODS

The databases Medline/PubMed, Embase, Web of Science, and Cochrane Library were searched for studies that estimated the effect of smoking on the risk of mortality in hip-fracture patients. Pooled analyses were conducted of the associations, expressed in relative risk (RR) and 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic. Study quality was assessed by the modified Newcastle-Ottawa Scale (NOS) and publication bias was evaluated by a funnel plot, Begg's and Egger's tests. Subgroup analyses were performed by study design, race/ethnicity, age ≥60 years, smoking status, and follow-up period.

RESULTS

A total of six articles involving 3739 hip-fracture patients were included in the meta-analysis. Our results indicate that ever-active smoking was significantly associated with an increased risk of death in hip-fracture patients (pooled RR=1.26; 95% CI: 1.08-1.46). In further subgroup analysis, the risk of death was significantly higher in ever-active smokers than in never smokers in White participants (pooled RR=1.23; 95% CI: 1.05-1.44) and elderly aged ≥60 years (pooled RR=1.19; 95% CI: 1.01-1.40), with no significant association in Asian participants (pooled RR=1.42; 95% CI: 0.95-2.11). Current smokers had more risk of death than never smokers (pooled RR=1.26; 95% CI: 1.08-1.46). The association was significant in follow-up periods of ≤1 year (pooled hazard ratio, HR=1.34; 95% CI: 1.05-1.71), 3 years (pooled HR=1.22; 95% CI: 1.05-1.43), and 5 years (pooled HR=1.26; 95% CI: 1.08-1.46).

CONCLUSIONS

Cigarette smoking is associated with an increased risk of mortality in hip-fracture patients, especially in elderly patients aged ≥60 years, current smokers, and White participants. With the extension of follow-up period, the effect on mortality of smoking is profound and lasting.

Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients

In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs.

PURPOSE

This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients.

METHODS

A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017.

RESULTS

Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture.

CONCLUSION

A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BACKGROUND

For displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF.

METHODS

A nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge.

RESULTS

By visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients' propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively).

CONCLUSION

Our research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.

Time to Surgery and Outcome in the Treatment of Proximal Femoral Fractures

BACKGROUND

It has not been conclusively established whether, or to what extent, the time to surgery affects mortality and the risk of complications after the surgical treatment of proximal femoral fractures.

METHODS

Data on 106 187 hospitalizations over the period 2015-2017 involving insurees of the German AOK health insurance company aged 20 and above were drawn from pseudonymized billing data and stratified in three subgroups: osteosynthesis for pertrochanteric fracture (PTF-OS: N = 52 358), osteosynthesis for femoral neck fracture (FNF-OS: N = 7970), and endoprosthesis for femoral neck fracture (FNF-EP: N = 45 859). Multivariate regression models were used to analyze the relation between preoperative in-hospital stay (time to surgery, TTS: 0 days [reference category], 1, 2, 3, 4-7 days) and mortality and general complications within 90 days, with risk adjustment for fracture site, operative method, age, sex, accompanying illnesses, and antithrombotic medication in the preceding year.

RESULTS

Mortality was significantly elevated only with PTF-OS, and only with a TTS of 2 days (odds ratio: 1.12 [95% confidence interval: (1.02; 1.23)]). General complications in relation to TTS were significantly elevated in the following situations: PTF-OS: 2 days: OR 1.24 [1.13; 1.37], 3 days: OR 1.33 [1.11; 1.60], 4-7 days: OR 1.47 [1.21; 1.78]; FNF-EP: 3 days: OR 1.21 [1.06; 1.37], 4-7 days: OR 1.42 [1.25; 1.62]; FNF-OS: 4-7 days: OR 1.86 [1.26; 2.73].

CONCLUSION

A prolonged time to surgery is associated with an elevated general complication risk depending on the site of the fracture and the type of surgical procedure used.

Hospital variation in the risk of infection after hip fracture surgery: a population-based cohort study including 29,598 patients from 2012-2017

Background and purpose - Understanding the key drivers of hospital variation in postoperative infections after hip fracture surgery is important for directing quality improvements. Therefore, we investigated variation in the risk of any infection, and subgroups of infections including pneumonia and sepsis after hip fracture surgery.Methods - In this nationwide population-based cohort study, all Danish patients aged ≥ 65 undergoing surgery for an incident hip fracture from 2012 to 2017 were included. Risk of postoperative infections, based on data from hospital registration (hospital-treated infections) and antibiotic dispensing (community-treated infections), were calculated using multilevel Poisson regression analysis. Hospital variation was evaluated by intra-class coefficient (ICC) and median risk ratio (MRR).Results - The risk of hospital-treated infection was 15%. The risk of community-treated infection was 24%. The adjusted risk varied between hospitals from 7.8-25% for hospital-treated infection and 16-34% for community-treated infection. The ICC indicated that 19% of the adjusted variance was due to hospital level for hospital-treated infection. The ICC for community-treated infections was 13%. The MRR showed a 2-fold increased risk for the average patient acquiring a hospital-treated infection at the highest risk hospital compared with the lowest risk hospital. For community-treated infection, the MRR was 1.4.Interpretation - Our results suggest that 20% of infections could be reduced by applying the top performing hospitals' approach. Nearly a 5th of the variation was at the hospital level. This suggests a more standardized approach to avoid postoperative infection after hip fracture surgery.Hip fracture is a leading cause of hospital admission among the elderly. The 30-day mortality following hip fracture surgery has been approximately 10% during the last few years in Denmark (Pedersen et al. 2017). Higher mortality after hip fracture has been associated with a range of hospital factors (Kristensen et al. 2016, Sheehan et al. 2016) and patient factors in observational studies (Roche et al. 2005). Furthermore, variation in 30-day mortality after hip fracture surgery has been observed between Danish hospitals, but not fully explained (Kristensen et al. 2019).

Risk of Hospitalized Falls and Hip Fractures in 22,103 Older Adults Receiving Mental Health Care vs 161,603 Controls: A Large Cohort Study

OBJECTIVES

To investigate the risk of hospitalized fall or hip fracture among older adults using mental health services.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Residents of a South London catchment aged >60 years receiving specialist mental health care between 2008 and 2016.

MEASURES

Falls and/or a hip fracture leading to hospitalization were ascertained from linked national records. Incidence rates and incidence rate ratios (IRRs) were age- and gender-standardized to the catchment population. Multivariable survival analyses were applied investigating falls and/or hip fractures as outcomes.

RESULTS

In 22,103 older adults, incidence rates were 60.1 per 1000 person-years for hospitalized falls and 13.7 per 1000 person-years for hip fractures, representing standardized IRRs of 2.17 [95% confidence interval (CI) 2.07-2.28] and 4.18 (3.79-4.60), respectively. The IRR for falls was high in those with substance-use disorder [IRR = 6.72 (5.35-8.33)], bipolar disorder [IRR = 3.62 (2.50-5.05)], depression [IRR = 2.28 (2.00-2.59)], and stress-related disorders [IRR = 2.57 (2.10-3.11)]. Hip fractures were increased in all populations (IRR > 2.5), with greatest risk in substance use disorders [IRR = 12.64 (7.22-20.52)], dementia [IRR = 4.38 (3.82-5.00)], and delirium [IRR = 4.03 (3.00-5.29)]. Comparing mental disorder subgroups with each other, after the adjustment for 25 potential confounders, patients with dementia and substance use had a significantly increased risk of falls, and patients with dementia also had an increased risk of hip fractures.

CONCLUSION AND IMPLICATIONS

Older people using mental health services have more than double the incidence of falls and 4 times the incidence of hip fractures compared to the general population. Although incidences differ between diagnostic subgroups, all groups have a higher incidence than the general population. Targeted interventions to prevent falls and hip fractures among older adult mental health service users are urgently needed.

In-Hospital Postoperative Pneumonia Following Geriatric Intertrochanteric Fracture Surgery: Incidence and Risk Factors

Purpose

The in-hospital death rate in cases of hip fracture ranges from 6% to 10%. Pneumonia is a serious complication for hip fracture patients that contributes to longer hospital stays and higher mortality rates; however, the prevalence and risk factors are not well established. To address this issue, the present study investigated the incidence of and risk factors for in-hospital postoperative pneumonia (IHPOP) following geriatric intertrochanteric fracture surgery.

Patients and Methods

Information on 1495 geriatric patients (>65 years) who underwent intertrochanteric fracture surgery at our hospital between October 2014 and December 2018 was extracted from a prospective hip fracture database and reviewed. Demographic information, clinical variables including surgical data, and preoperative laboratory indices that could potentially influence IHPOP were analyzed. Receiver operating characteristic curve analysis was performed and the optimum cutoff value for quantitative data was determined. Univariate and multivariate analyses were carried out to identify risk factors for IHPOP.

Results

The incidence of IHPOP following geriatric intertrochanteric fracture surgery was 3.5% (53/1495 cases). The multivariate analysis showed that age >82 years (odds ratio [OR]=2.54, p=0.004), male sex (OR=2.13, p=0.017), chronic respiratory disease (OR=5.02, p<0.001), liver disease (OR=3.39, p=0.037), urinary tract infection (OR=8.46, p=0.005), creatine kinase (CK) MB>20 U/l (OR=2.31, p=0.020), B-type natriuretic peptide (BNP) ≥75 ng/l (OR=4.02, p=0.001), and d-dimer >2.26 mg/l (OR=2.69, p=0.002) were independent risks factor for the incidence of IHPOP following geriatric intertrochanteric fracture surgery.

Conclusion

The incidence of IHPOP was 3.5% following geriatric intertrochanteric fracture surgery; age, male sex, chronic respiratory disease, liver disease, urinary tract infection, CKMB, BNP, and d-dimer were significant risk factors. Targeted preoperative management based on these factors could reduce the risk of IHPOP and mortality in these patients.

Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty?

Background

This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty.

Methods

Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables.

Results

The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002).

Discussion

Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery.

Level of evidence

Prognostic level III

Mortality effects of timing alternatives for hip fracture surgery

BACKGROUND

The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.

METHODS

We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.

RESULTS

Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).

INTERPRETATION

Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture

INTRODUCTION

We conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD.

METHODS

This study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality.

RESULTS

The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD.

CONCLUSIONS

In elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.

Discharge destination following hip fracture in Canada among previously community-dwelling older adults, 2004-2012: database study

Little is known about post-acute care following hip fracture surgery. We investigated discharge destinations from surgical hospitals for nine Canadian provinces. We identified significant heterogeneity in discharge patterns across provinces suggesting different post-acute recovery pathways. Further work is required to determine the impact on patient outcomes and health system costs.

INTRODUCTION

To examine discharge destinations by provinces in Canada, adjusting for patient, injury, and care characteristics.

METHODS

We analyzed population-based hospital discharge abstracts from a national administrative database for community-dwelling patients who underwent hip fracture surgery between 2004 and 2012 in Canada. Discharge destination was categorized as rehabilitation, home, acute care, and continuing care. Multinomial logistic regression modeling compared proportions of discharge to rehabilitation, acute care, and continuing care versus home between each province and Ontario. Adjusted risk differences and risk ratios were estimated.

RESULTS

Of 111,952 previously community-dwelling patients aged 65 years or older, 22.5% were discharged to rehabilitation, 31.6% to home, 27.0% to acute care, and 18.2% to continuing care, with significant variation across provinces (p < 0.001). The proportion of discharge to rehabilitation ranged from 2.4% in British Columbia to 41.0% in Ontario while the proportion discharged home ranged from 20.3% in Prince Edward Island to 52.2% in British Columbia. The proportion of discharge to acute care ranged from 15.2% in Ontario to 58.8% in Saskatchewan while the proportion discharged to continuing care ranged from 9.3% in Manitoba and Prince Edward Island to 22.9% in New Brunswick. Adjusting for hospital type changed the direction of the provincial effect on discharge to continuing care in two provinces, but statistical significance remained consistent with the primary analysis.

CONCLUSIONS

Discharge destination from the surgical hospital after hip fracture is highly variable across nine Canadian provinces. Further work is required to determine the impact of this heterogeneity on patient outcomes and health system costs.

Impact of Direct Oral Anticoagulants in Patients With Hip Fractures

OBJECTIVE

To assess the impact of direct oral anticoagulant (DOAC) intake compared with Coumadin (COU) in patients suffering hip fractures (HFs).

DESIGN

Retrospective cohort analysis.

SETTING

Level 1 Trauma Center.

INTERVENTION

Timing of surgical hip fixation.

PATIENTS

Three-hundred twenty patients 65 years of age or older with isolated HF were enrolled into the study: 207 (64.7%) without any antithrombotic therapy (no-ATT), 59 (18.4%) on COU, and 54 (16.9%) on DOACs.

MAIN OUTCOME MEASUREMENTS

Time to surgery, blood loss, mortality, hospital length of stay, red blood cell transfusion, use of reversal agents, and Charlson Comorbidity Index.

RESULTS

Patients on COU and DOACs had a higher Charlson Comorbidity Index compared with the no-ATT group (P < 0.0001). Despite the fact that significantly more patients received reversal agents in the COU group compared with DOAC medication (P < 0.0001), percentage of transfused patients were similar (54.2% vs. 53.7%). Time to surgery was significantly shorter in the no-ATT group when compared with DOAC patients (12-29.5 hours, respectively). No difference in postoperative hemorrhage, intensive care unit length of stay, and mortality was observed between groups.

CONCLUSIONS

DOAC medication in HF patients caused long elapse time until surgical repair. We found no evidence of higher bleeding rates in HF patients on DOACs compared with COUs. Earlier HF fixation might be indicated in DOAC patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System?

BACKGROUND

Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.

QUESTIONS/PURPOSES

(1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?

METHODS

We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.

RESULTS

We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).

CONCLUSIONS

These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Determinants of mortality after hip fracture surgery in Sweden: a registry-based retrospective cohort study

Surgery for hip fractures is associated with high mortality and morbidity. The causes of poor outcome are not fully understood and may be related to other factors than the surgery itself. The relative contributions of patient, surgical, anaesthetic and structural factors have seldom been studied together. This study, a retrospective registry-based cohort study of 14 932 patients undergoing hip fracture surgery in Sweden from 1st of January 2014 to 31st of December 2016, aimed to identify important predictors of mortality post-surgery. The independent predictive power of our included variables was examined using Cox proportional hazards modeling with all-cause mortality at longest follow-up as the outcome. Twelve independent variables were considered as interrelated ‘exposures’ and their individual adjusted effect within a single model were evaluated. Kaplan-Meier curves were also generated. Crude mortality rates were 8.2% at 30 days (95% CI 7.7–8.6%) and 23.6% at 365 days (95% CI 22.9–24.2%). Of the 12 factors entered into the Cox regression analysis, age (aHR1.06, p < 0.001), male gender (aHR 1.45, p < 0.001), ASA-PS-class (ASA 1&2 reference; ASA 3 aHR 2.12; ASA 4 aHR 4.79; ASA 5 aHR 12.57 respectively, p < 0.001) and PACU-LOS (aHR 1.01, p < 0.001) were significantly associated with mortality at longest follow-up (up to 3 years). University hospital status was protective (aHR 0.83, p < 0.001) in the same model. Age, gender and ASA-PS-class were strong predictors of mortality after surgery for hip fractures in Sweden. University hospital status and length of stay in the postoperative care unit were also identified as modifiable risk factors after multivariable adjustment and require confirmation in future studies.

Medical Costs of Delayed Hip Fracture Surgery

BACKGROUND

Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs.

METHODS

We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days).

RESULTS

The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours.

CONCLUSIONS

Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery.

LEVEL OF EVIDENCE

Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.

Reporting and evaluating wait times for urgent hip fracture surgery in Ontario, Canada

BACKGROUND

Although a delay of 24 hours for hip fracture repair is associated with medical complications and costs, it is unknown how long patients wait for surgery for hip fracture. We describe novel methods for measuring exact urgent and emergent surgical wait times (in hours) and the factors that influence them.

METHODS

Adults aged 45 years and older who underwent surgery for hip fracture (the most common urgently performed procedure) in Ontario, Canada, between 2009 and 2014 were eligible. Validated data from linked health administrative databases were used. The primary outcome was the time elapsed from hospital arrival recorded in the National Ambulatory Care Reporting System until the time of surgery recorded in the Discharge Abstract Database (in hours). The influence of patient, physician and hospital factors on wait times was investigated using 3-level, hierarchical linear regression models.

RESULTS

Among 42 230 patients with hip fracture, the mean (SD) wait time for surgery was 38.76 (28.84) hours, and 14 174 (33.5%) patients underwent surgery within 24 hours. Variables strongly associated with delay included time for hospital transfer (adjusted increase of 26.23 h, 95% CI 25.38 to 27.01) and time for preoperative echocardiography (adjusted increase of 18.56 h, 95% CI 17.73 to 19.38). More than half of the hospitals (37 of 72, 51.4%), compared with 4.8% of surgeons and 0.2% of anesthesiologists, showed significant differences in the risk-adjusted likelihood of delayed surgery.

INTERPRETATION

Exact wait times for urgent and emergent surgery can be measured using Canada's administrative data. Only one-third of patients received surgery within the safe time frame (24 h). Wait times varied according to hospital and physician factors; however, hospital factors had a larger impact.

Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery

IMPORTANCE

Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications.

OBJECTIVE

To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases.

DESIGN, SETTING, AND PARTICIPANTS

Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs).

EXPOSURE

Time elapsed from hospital arrival to surgery (in hours).

MAIN OUTCOMES AND MEASURES

Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia).

RESULTS

Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89).

CONCLUSIONS AND RELEVANCE

Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

Mortality by Timing of Hip Fracture Surgery: Factors and Relationships at Play

In hip fracture care, it is disputed whether mortality worsens when surgery is delayed. This knowledge gap matters when hospital managers seek to justify resource allocation for prioritizing access to one procedure over another. Uncertainty over the surgical timing-death association leads to either surgical prioritization without benefit or the underuse of expedited surgery when it could save lives. The discrepancy in previous findings results in part from differences between patients who happened to undergo surgery at different times. Such differences may produce the statistical association between surgical timing and death in the absence of a causal relationship. Previous observational studies attempted to adjust for structure, process, and patient factors that contribute to death, but not for relationships between structure and process factors, or between patient and process factors. In this article, we (1) summarize what is known about the factors that influence, directly or indirectly, both the timing of surgery and the occurrence of death; (2) construct a dependency graph of relationships among these factors based explicitly on the existing literature; (3) consider factors with a potential to induce covariation of time to surgery and the occurrence of death, directly or through the network of relationships, thereby explaining a putative surgical timing-death association; and (4) show how age, sex, dependent living, fracture type, hospital type, surgery type, and calendar period can influence both time to surgery and occurrence of death through chains of dependencies. We conclude by discussing how these results can inform the allocation of surgical capacity to prevent the avoidable adverse consequences of delaying hip fracture surgery.

Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Hip Fracture

BACKGROUND

Prior studies have examined the relationship between surgeon and hospital volumes and outcome following hip fracture surgical procedures, but the results have been inconclusive. The purpose of this study was to assess the hip fracture volume-outcome relationship by analyzing data from a large, managed care registry.

METHODS

The Kaiser Permanente Hip Fracture Registry prospectively records information on surgically treated hip fractures within the managed health-care system. Using this registry, all surgically treated hip fractures in patients 60 years of age or older were identified. Surgeon and hospital volume were defined as the number of hip fracture surgical procedures performed in the preceding 12 months and were divided into tertiles (low, medium, and high). The primary outcome was mortality at 1 year postoperatively. Secondary outcomes were mortality at 30 and 90 days postoperatively as well as reoperation (lifetime), medical complications (90-day), and unplanned readmission (30-day). To determine the relationship between volume and these outcome measures, multivariate logistic and Cox proportional hazards regression were performed, controlling for potentially confounding variables.

RESULTS

Of 14,294 patients in the study sample, the majority were female (71%) and white (79%), and the mean age was 81 years. The overall mortality rate was 6% at 30 days, 11% at 90 days, and 21% at 1 year. We did not find an association between surgeon or hospital volume and mortality at 30 days, 90 days, or 1 year (p > 0.05). There was also no association between surgeon or hospital volume and reoperation, medical complications, or unplanned readmission (p > 0.05).

CONCLUSIONS

In this analysis of hip fractures treated in a large integrated health-care system, the observed rates of mortality, reoperation, medical complications, and unplanned readmission did not differ by surgeon or hospital volume. In contrast to other orthopaedic procedures, such as total joint arthroplasty, our data do not suggest that hip fractures need to be preferentially directed toward high-volume surgeons or hospitals for treatment.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient and system factors of time to surgery after hip fracture: a scoping review

OBJECTIVES

It is disputed whether the time a patient waits for surgery after hip fracture increases the risk of in-hospital death. This uncertainty matters as access to surgery following hip fracture may be underprioritised due to a lack of definitive evidence. Uncertainty in the available evidence may be due to differences in characteristics of patients, their injury and their care. We summarised the literature on patients and system factors associated with time to surgery, and collated proposed mechanisms for the associations.

METHODS

We used the framework developed by Arksey and O'Malley and Levac et al for synthesis of factors and mechanisms of time to surgery after hip fracture in adults aged >50 years, published in English, between 1 January 2000 and 28 February 2017, and indexed in MEDLINE, EMBASE, CINAHL or Ageline. Proposed mechanisms for reported associations were extracted from discussion sections.

RESULTS

We summarised evidence from 26 articles that reported on 24 patient and system factors of time to surgery post hip fracture. In total, 16 factors were reported by only one article. For 16 factors we found proposed mechanisms for their association with time to surgery which included surgical readiness, available resources, prioritisation and out-of-hours admission.

CONCLUSIONS

We identified patient and system factors associated with time to surgery after hip fracture. This new knowledge will inform evaluation of the putative timing-death association. Future interventions should be designed to influence factors with modifiable mechanisms for delay.