Improving morbidity and mortality in hip fragility fractures

PURPOSE OF REVIEW

Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system.

RECENT FINDINGS

There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality.

SUMMARY

HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Secondary osteoporosis prevention: three-year outcomes from a Fracture Liaison Service in elderly hip fracture patients

BACKGROUND

Hip fractures are the most serious fragility fractures due to their associated disability, higher hospitalization costs and high mortality rates. Fracture Liaison Service (FLS) programs have enhanced the management of osteoporosis-related fractures and have shown their clinical effectiveness.

AIMS

To analyze the effect of the implementation of a FLS model of care over the survival and mortality rates following a hip fracture.

METHODS

We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture before and after the implementation of the FLS in our center (between January 2016 and December 2019). Patients were followed for three years after the index date. Mortality, complications and refracture rates were compared between the two groups using a Multivariate Cox proportional hazard model.

RESULTS

A total of 1366 patients were included in this study (353 before FLS implementation and 1013 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation (79.3% vs 12.5%; p < 0.01) and there was an increase in adherence to treatment (51.7% vs 30.2%; p < 0.01). A total of 413 (40.8%) patients after FLS implementation and 141 (39.9%) individuals before (p = 0.47) died during the three-years follow-up period. A second fracture occurred in 101 (10.0%) patients after FLS implementation and 37 (10.5%) individuals before (p = 0.78). Patients after the implementation of the FLS protocol had a lower all cause one-year mortality [adjusted Hazard Ratio (HR) 0.74 (0.57-0.94)] and a decreased risk of suffering a second osteoporotic fracture [adjusted HR 0.54 (0.39-0.75) in males and adjusted HR 0.46 (0.30-0.71) in females].

CONCLUSIONS

The implementation of a FLS protocol was associated with a lower all-cause one-year mortality rate and a higher survivorship in elderly hip fracture patients. However, no three-year mortality rate differences were observed between the two groups. We also found a reduction in the complication and second-fracture rates.

Mortality following fragility hip fracture in China: a record linkage study

Mortality risk declined over time. Patients with fragility hip fracture experienced an approximate ninefold excess mortality, peaking shortly after fracture, in comparison with that of the general population. Continuous efforts in lowering the occurrence of hip fracture have the potential to improve the survival of the elderly population in China.

PURPOSE

Hip fractures in older adults often lead to an elevated risk of death. However, few studies investigated mortality risk following hip fracture in mainland China. This retrospective cohort study aimed to evaluate the crude mortality and excess mortality after fragility hip fractures in Lishui residents aged 50 years and older.

METHODS

Patients having a fragility hip fracture between October 2013 and August 2019 were identified from the Lishui District Inpatient Data Collection and followed up until August 2020. Death information was ascertained from the linked death registry records. We calculated the follow-up mortality rate and corresponding 95% confidence intervals (CIs) as well as the standard mortality ratios (SMRs) in comparison with the mortality rates of Lishui residents.

RESULTS

During the study period, a total of 808 patients (63.4% females) with an average age of 75 years were admitted for fragility hip fractures. The 1st, 2nd, and 3rd year follow-up mortality rates were 16.51, 6.06, and 5.03 per 100 person-year, respectively. The SMRs were 8.46 (6.94, 9.97), 5.74 (4.86, 6.63), and 4.63 (3.98, 5.27) for the 1st, 2nd, and 3rd year following fragility hip fracture.

CONCLUSION

Although mortality risk declined over time, patients with fragility hip fracture experienced an approximate ninefold excess mortality, peaking shortly after fracture, in comparison with that of the general population. Continuous efforts in lowering the occurrence of hip fracture have the potential to improve the survival of the elderly population in China.

'Skeletal Age' for mapping the impact of fracture on mortality

Background

Fragility fracture is associated with an increased risk of mortality, but mortality is not part of doctor-patient communication. Here, we introduce a new concept called 'Skeletal Age' as the age of an individual's skeleton resulting from a fragility fracture to convey the combined risk of fracture and fracture-associated mortality for an individual.

Methods

We used the Danish National Hospital Discharge Register which includes the whole-country data of 1,667,339 adults in Denmark born on or before January 1, 1950, who were followed up to December 31, 2016 for incident low-trauma fracture and mortality. Skeletal age is defined as the sum of chronological age and the number of years of life lost (YLL) associated with a fracture. Cox's proportional hazards model was employed to determine the hazard of mortality associated with a specific fracture for a given risk profile, and the hazard was then transformed into YLL using the Gompertz law of mortality.

Results

During the median follow-up period of 16 years, there had been 307,870 fractures and 122,744 post-fracture deaths. A fracture was associated with between 1 and 7 years of life lost, with the loss being greater in men than women. Hip fractures incurred the greatest loss of life years. For instance, a 60-year-old individual with a hip fracture is estimated to have a skeletal age of 66 for men and 65 for women. Skeletal Age was estimated for each age and fracture site stratified by gender.

Conclusions

We propose 'Skeletal Age' as a new metric to assess the impact of a fragility fracture on an individual's life expectancy. This approach will enhance doctor-patient risk communication about the risks associated with osteoporosis.

Funding

National Health and Medical Research Council in Australia and Amgen Competitive Grant Program 2019.

Fracture Liaison Service for Hip Fractures: Is It A Game Changer?

BACKGROUND

Osteoporosis is a common medical condition in older ages. A devastating result of osteoporosis may be a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world.

OBJECTIVES

To evaluate the impact of the fracture liaison service (FLS) model in the orthopedic department on patient compliance following hip fracture.

METHODS

We performed a retrospective review of all patients with hip fracture who were involved with FLS. We collected data regarding kidney function, calcium levels, parathyroid hormone levels, and vitamin D levels at admission. We educated the patient and family, started vitamin D and calcium supplementation and recommended osteoporotic medical treatment. We phoned the patient 6-12 weeks following the fracture to ensure treatment initiation.

RESULTS

From June 2018 to June 2019 we identified 166 patients with hip fracture who completed at least one year of follow-up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. Nine patients (5%) died at median of 109 days. Following our intervention, 161 patients (96%) were discharged with a specific osteoporotic treatment recommendation; 121 (73%) received medication for osteoporosis on average of < 3 months after surgery. We recommended on injectable medications; however, 51 (42%) were treated with oral biphsophonate.

CONCLUSIONS

FLS improved the compliance rate of osteoporotic medical treatment and should be a clinical routine in every medical center.

Operative treatment of fragility fractures of the pelvis is connected with lower mortality. A single institution experience

Background

Fragility fractures of the pelvis (FFP) represent an increasing clinical entity. Until today, there are no guidelines for treatment of FFP. In our center, recommendation for operative treatment was given to all patients, who suffered an FFP type III and IV and to patients with an FFP type IIwith unsuccessful non-operative treatment. We performed a retrospective observational study and investigated differences between fracture classes and management alternatives. We hypothetized that operative treatment may reduce mortality.

Materials and methods

The medical charts and radiographs of 362 patients were analysed. Patient demographics, FFP-classification, length of hospital stay (LoS), type of treatment, general and surgery-related complications, mortality, Short Form-8 physical component score (SF-8 PCS) and mental component score (SF-8 MCS), Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were documented.

Results

238 patients had FFP type II and 124 FFP type III and IV. 52 patients with FFP type II (21.8%) and 86 patients with FFP type III and IV (69.4%) were treated operatively (p<0.001). Overall mortality did not differ between the fracture classes (p = 0.127) but was significantly lower in the operative group (p<0.001). Median LoS was significantly higher in FFP type III and IV (p<0.001) and in operated patients (p<0.001). There were more in-hospital complications in patients with FFP type III and IV (p = 0.001) and in the operative group (p = 0.006). More patients of the non-operative group were mobile (p<0.001) and independent (p<0.001) at discharge. Half of the patients could not return in their living environment.203 of the 235 surviving patients (86%) answered the questionnaires after a mean follow-up time of 38 months. SF-8 PCS, SF-8 MCS and PMS did not differ between the fracture classes and treatment groups. Pain perception was higher in the operated group (p = 0.013).

Conclusion

In our study, we observed that operative treatment of FFP provides low mortality rates, although LoS and in-hospital complications were higher in the operative group. At discharge, the non-operative group was more mobile and independent. At follow up, quality of life and mobility were comparable between the groups. Further prospective studies are needed to clarify the impact of operative treatment of FFP on mortality and functional outcome.

[Influence of early hip fracture surgery in the elderly on mortality, readmissions, dependence and quality of life.]

OBJECTIVE

In spite of technical advances, hip fracture causes high mortality in the elderly. We wanted to know early surgery influence to mortality during admission, one year and after five years, as well as readmissions at one month and one year. We also wanted to know how dependence and Health-Related Quality of Life (HRQOL) evolved in the twelve months of follow-up and what factors were associated with poor patient evolution.

METHODS

A prospective observational study was made in patients over 65 years of age treated for osteoporotic hip fracture in a level III hospital between 2010- 2012, with consecutive sampling. We evaluated functionality (Barthel) and quality of life (EuroQol-5D) basal (before fracture), within 30 days, within six and twelve months; readmissions within the 30 days and within one year; and mortality during admission; within one and five years. We used the statistical program SPSS Version 25.0 for the statistical analysis.

RESULTS

We followed 327 patients of 82.9 (SD: 6.9) years of means, 258 (78.9%) were women. Fifty-four (45.9%) were treated within 24 hours and 237 (72.5%) within 48 hours. They returned 14 (4.3%) within the 30 days and 44 (13.5%) within the one year. There were 8 deaths during admission (2.4%) and 61 (19.2%) in the first year and 185 (54,6%) within five years. The pre-fracture quality of life was 0.43 median (0.24-0.74), at the month 0.15 (0.07-0.28), at six months 0.26 (0, 13-0.59) and at twelve 0.24 (0.15-0.58). The previous functionality was 85.0 (55.0-100) at the month 35.0 (20.0-60.0) and 60.0 (25.0-85.0) at six and twelve months. There were significant differences between all visits except between six and twelve months.

CONCLUSIONS

The patients get worse significantly at the month of surgery and recover in the six months, remaining at twelve, without reaching the baseline value. The results in mortality and readmissions per year are worse for men and older. Early surgery does not reduce mortality, but re-admissions to the year.

Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service

Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group.

PURPOSE

To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up.

METHODS

This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening.

RESULTS

Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3-2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3-1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2-1.7), and other single fractures (HR = 1.4, 95%CI 1.1-1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50-65 age group, patients 66 years and older had a higher risk of death (for 66-70 age group: HR = 2.5, 95%CI 1.9-3.3; for 71-80: HR = 4.3, 95%CI 3.5-5.4; and for 81+: HR = 10.6, 95%CI 8.7-13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5-0.6) than males.

CONCLUSIONS

Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.

Fracture liaison service and mortality in elderly hip fracture patients: a prospective cohort study

Osteoporosis is a metabolic disorder that results in increased bone fragility and risk of fractures. Hip fracture is the most important fragility fracture. Fracture Liaison Service (FLS) is a secondary prevention model which identifies patients at risk for fragility fractures. The introduction of an intensive FLS model could decrease 1-year-mortality of hip fracture patients.

INTRODUCTION

Hip fractures are a clinical manifestation of osteoporosis, and these patients are at risk of premature death and suffering subsequent fractures. FLS is an approach for secondary facture prevention by identifying patients with fragility fractures and initiating the appropriate treatment. Our objective is to analyze the effect of the FLS model over the first-year mortality rates following a hip fracture.

METHODS

We conducted a prospective cohort study on patients over 60 years of age who suffered a hip fracture during two consecutive years, before and after the implementation of the FLS in our center (i.e., between January 2016 and December 2017). Patients' information was withdrawn from our local computerized database. Patients were followed for 1 year after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model.

RESULTS

A total of 724 individuals were included in this study (i.e., 357 before FLS implementation and 367 after FLS implementation). Anti-osteoporotic drugs were more frequently prescribed after FLS implementation [275 (74.9%) vs 44 (12.3%); p < 0.01]. A total of 74 (20.2%) patients after FLS implementation and 92 (25.8%) individuals before FLS implementation (p = 0.07) died during the follow-up period. A second fracture occurred in 17 (4.6%) patients after FLS implementation and 13 (3.6%) individuals before FLS implementation (p = 0.50). Patients who were treated with anti-osteoporotic drugs after the implementation of the FLS protocol had a lower 1-year mortality compared with patients managed before the implementation of the FLS protocol (treated or not treated with anti-osteoporotic drugs) [adjusted hazard ratio (HR) 0.66; 95% confidence interval (CI) 0.47-0.94; p < 0.05].

CONCLUSIONS

We did not observe significant 1-year-mortality differences following a hip fracture between patients treated before the implementation of an FLS protocol and patients treated after its implementation. The application of the FLS did not affect the risk of suffering a second osteoporotic fracture. However, patients treated with anti-osteoporotic drugs in an FLS context had a lower mortality rate compared with patients managed before the implementation of the FLS.

LEVEL OF CLINICAL EVIDENCE

2.

Impact of osteoporotic fracture type and subsequent fracture on mortality: the Tromsø Study

Less is known about the impact of non-hip non-vertebral fractures (NHNV) on early death. This study demonstrated increased risk of dying following hip and NHNV fractures which was further increased by a subsequent fracture. This highlights the importance of early intervention to prevent both initial and subsequent fractures and improve survival.

INTRODUCTION

Osteoporotic fractures are a major health concern. Limited evidence exists on their impact on mortality in ageing populations. This study examined the contribution of initial fracture type and subsequent fracture on mortality in a Norwegian population that has one of the highest rates of fractures.

METHODS

The Tromsø Study is a prospective population-based cohort in Norway. Women and men aged 50+ years were followed from 1994 to 2010. All incident hip and non-hip non-vertebral (NHNV) fractures were registered. NHNV fractures were classified as either proximal or distal. Information on self-reported co-morbidities, lifestyle factors, general health and education level was collected. Multivariable Cox models were used to quantify mortality risk with incident and subsequent fractures analysed as time-dependent variables.

RESULTS

Of 5214 women and 4620 men, 1549 (30%) and 504 (11%) sustained a fracture, followed by 589 (38%) and 254 (51%) deaths over 10,523 and 2821 person-years, respectively. There were 403 (26%) subsequent fractures in women and 68 (13%) in men. Hip fracture was associated with a two-fold increase in mortality risk (HR 2.05, 95% CI 1.73-2.42 in women and 2.49, 95% CI 2.00-3.11 in men). Proximal NHNV fractures were associated with 49% and 81% increased mortality risk in women and men (HR 1.49, 95% CI 1.21-1.84 and 1.81, 95% CI 1.37-2.41), respectively. Distal NHNV fractures were not associated with mortality. Subsequent fracture was associated with 89% and 77% increased mortality risk in women and men (HR 1.89, 95% CI 1.52-2.35 and 1.77, 95% CI 1.16-2.71), respectively.

CONCLUSION

Hip, proximal NHNV and subsequent fractures were significantly associated with increased mortality risk in the elderly, highlighting the importance of early intervention.

The association between type 2 diabetes mellitus, hip fracture, and post-hip fracture mortality: a multi-state cohort analysis

Type 2 diabetes mellitus (T2DM) is associated with an excess risk of fractures and overall mortality. This study compared hip fracture and post-hip fracture mortality in T2DM and non-diabetic subjects. The salient findings are that subjects in T2DM are at higher risk of dying after suffering a hip fracture.

INTRODUCTION

Previous research suggests that individuals with T2DM are at an excess risk of both fractures and overall mortality, but their combined effect is unknown. Using multi-state cohort analyses, we estimate the association between T2DM and the transition to hip fracture, post-hip fracture mortality, and hip fracture-free all-cause death.

METHODS

Population-based cohort from Catalonia, Spain, including all individuals aged 65 to 80 years with a recorded diagnosis of T2DM on 1 January 2006; and non-T2DM matched (up to 2:1) by year of birth, gender, and primary care practice.

RESULTS

A total of 44,802 T2DM and 81,233 matched controls (53% women, mean age 72 years old) were followed for a median of 8 years: 23,818 died without fracturing and 3317 broke a hip, of whom 838 subsequently died. Adjusted HRs for hip fracture-free mortality were 1.32 (95% CI 1.28 to 1.37) for men and 1.72 (95% CI 1.65 to 1.79) for women. HRs for hip fracture were 1.24 (95% CI 1.08 to 1.43) and 1.48 (95% CI 1.36 to 1.60), whilst HRs for post-hip fracture mortality were 1.28 (95% CI 1.02 to 1.60) and 1.57 (95% CI 1.31 to 1.88) in men and women, respectively.

CONCLUSION

T2DM individuals are at increased risk of hip fracture, post-hip fracture mortality, and hip fracture-free death. After adjustment, T2DM men were at a 28% higher risk of dying after suffering a hip fracture and women had 57% excess risk of post-hip fracture mortality.

Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study

OBJECTIVE

To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome.

DESIGN

Retrospective.

SETTING

Two trauma centers.

PATIENTS AND METHODS

Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively.

MAIN OUTCOME MEASUREMENTS

Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up.

RESULTS

At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910).

CONCLUSION

Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.

LEVEL OF EVIDENCE

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

Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study

OBJECTIVE

To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome.

DESIGN

Retrospective.

SETTING

Two trauma centers.

PATIENTS AND METHODS

Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively.

MAIN OUTCOME MEASUREMENTS

Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up.

RESULTS

At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910).

CONCLUSION

Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival.

LEVEL OF EVIDENCE

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

Assessing risk factors of non-fatal outcomes amid a competing risk of mortality: the example of hip fracture

The Fine-Gray method is often used instead of Cox regression to account for competing risks of death in time-to-event analyses for non-fatal outcomes. A series of examples using well-known risk factors of hip fracture in an older cohort with substantial competing mortality demonstrates that the Fine-Gray approach can yield estimates that implausibly contradict long-established associations, while Cox regression preserves them. Cox regression is generally preferred for risk factor-outcome associations even in the presence of competing risk of death.

INTRODUCTION

Factors like age, sex, and race are associated not only with risk of hip fracture but also with mortality. Substantial misunderstanding remains regarding the appropriate statistical approach to account for the competing risk of mortality.

METHODS

In the Cardiovascular Health Study, an ongoing cohort study of 5888 older adults, we followed participants for incident hip fracture from their 1992-1993 visit through June 2014. We contrasted the conventional cause-specific Cox analysis, which censors individuals at the time of death, with the Fine-Gray (FG) approach, which extends participant follow-up even after death, to estimate the association of well-established demographic and clinical factors with incident hip fracture.

RESULTS

For age, current smoking and sex, Cox and FG methods yielded directionally concordant but quantitatively different strengths of association. For example, the Cox hazard ratio (HR) for a 5-year increment in age was 1.74 (95% CI, 1.61-1.87), while the corresponding FG HR was 1.16 (1.09-1.24). In contrast, the FG approach estimated a stronger association of hip fracture with sex. The two approaches yielded nearly identical results for race. For diabetes and kidney function, the estimates were discordant in direction, and the FG HRs suggested effects that were in the opposite direction of well-understood and widely accepted associations.

CONCLUSIONS

Cause-specific Cox models provide appropriate estimates of hazard for non-fatal outcomes like hip fracture even in the presence of competing risk of mortality. The Cox approach estimates hazard in the population of individuals who have not yet had an incident hip fracture and remain alive, which is typically the group of clinical interest. The Fine-Gray method estimates hazard in a hypothetical population that can yield misleading inferences about risk factors in populations of clinical interest.

Incidence and Mortality of Osteoporotic Refractures in Korea according to Nationwide Claims Data

PURPOSE

Studies on the incidence and mortality of refractures after primary osteoporotic fracture are limited by the relatively rare incidence of such refractures and small sample sizes. The objectives of this research were: 1) to determine the incidence of osteoporotic refractures and fracture locations and 2) to assess mortality rates associated with osteoporotic refracture over a median follow up of 3 years using nationwide claim database.

MATERIALS AND METHODS

Patients over 50 years of age who had an osteoporotic fracture that was confirmed operationally were enrolled. Refracture was defined as that after 6 months of an untreated period. Mortality rate was calculated using the Charlson comorbidity index and was analyzed using Cox proportional hazards regression analysis.

RESULTS

A total of 18956 first-time instances of osteoporotic fracture were reported between 2007 and 2012 after a median follow up of 3.1 years (range, 1 to 7 years). Among 18956 patients, 2941 (15.50%) experienced refracture. After follow up for 1 year, cumulative mortality rates for re-fracture and non-refracture groups were 9.1% and 7.2%, respectively. After adjusting for covriates, mortality rate was 1.2 times greater in patients with re-fracture than in patients without re-fracture over a median follow up of 3 years (hazard ratio: 1.20, 95% confidence interval: 1.08-1.34, p<0.001).

CONCLUSION

The incidence of osteoporotic re-fracture in this nationwide study was 15.5%, and the mortality rate of re-fracture patients was 1.2 times higher than that of non-refracture patients over a median follow up of 3 years.

Bisphosphonates and mortality: confounding in observational studies?

Numerous observational studies suggest that bisphosphonates reduce mortality. This study showed that bisphosphonate use is associated with lower mortality within days of treatment, although the association was not significant until the second week. Such an early association is consistent with confounding, although an early treatment effect cannot be ruled out.

INTRODUCTION

The purpose of this study was to examine whether confounding explains why numerous observational studies show that bisphosphonate use is associated with lower mortality. To this end, we examined how soon after treatment initiation a lower mortality rate can be observed. We hypothesized that, due to confounding, the association would be observed immediately.

METHODS

This was a retrospective cohort study of hip fracture patients discharged from Swedish hospitals between 1 July 2006 and 31 December 2015. The data covered 260,574 hip fracture patients and were obtained from the Swedish Hip Fracture Register and national registers. Of the 260,574 patients, 49,765 met all eligibility criteria and 10,178 were pair matched (bisphosphonate users to controls) using time-dependent propensity scores. The matching variables were age, sex, diagnoses, prescription medications, type of hip fracture, type of surgical procedure, known or suspected dementia, and physical functioning status.

RESULTS

Over a median follow-up of 2.8 years, 2922 of the 10,178 matched patients died. The mortality rate was 7.9 deaths per 100 person-years in bisphosphonate users and 9.4 deaths in controls, which corresponded to a 15% lower mortality rate in bisphosphonate users (hazard ratio 0.85, 95% confidence interval 0.79-0.91). The risk of death was lower in bisphosphonate users from day 6 of treatment, although the association was not significant until the second week.

CONCLUSION

Bisphosphonate use was associated with lower mortality within days of treatment initiation. This finding is consistent with confounding, although an early treatment effect cannot be ruled out.

History of cardiovascular disease and cardiovascular biomarkers are associated with 30-day mortality in patients with hip fracture

Hip fractures are associated with increased mortality and it is important to identify risk factors. This study demonstrates that preexisting cardiovascular disease as well as cardiovascular biomarkers that are associated with increased 30-day mortality. These findings can be used to identify high-risk patients who might benefit from specialized care.

INTRODUCTION

This study investigates the association between cardiovascular disease (CVD), cardiovascular biomarkers, and 30-day mortality following a hip fracture.

METHODS

The Danish National Patient Registry was used to investigate the association between CVD and mortality following hip fracture in a nationwide population-based cohort study. In a subset of the included patients (n = 355), blood samples were available from a local biobank. These samples were used for analyzing the association between specific biochemical markers and mortality. The primary outcome was 30-day mortality.

RESULTS

A total of 113,211 patients were included in the population-based cohort study. Among these, heart failure was present in 9.4%, ischemic heart disease in 15.9%, and ischemic stroke in 12.0%. Within 30 days after the hip fracture, 11,488 patients died, resulting in an overall 30-day mortality of 10.1%. The 30-day mortality was significantly increased in individuals with preexisting CVD with multivariably adjusted odds ratios of 1.69 (95% confidence interval, 1.60-1.78) for heart failure, 1.23 (1.17-1.29) for ischemic heart disease, and 1.06 (1.00-1.12) for ischemic stroke. In the local database including 355 patients, 41 (11.5%) died within 30 days. The multivariably adjusted odds ratio for 30-day mortality increased with increasing NT-proBNP (2.36 [1.53-3.64] per quartile) and decreased with increasing HDL cholesterol (0.58 [0.41-0.82] per quartile). On this basis, we established a model for predicting the probability of death based on the biochemical markers.

CONCLUSION

Preexisting CVD was associated with increased 30-day mortality after a hip fracture. Furthermore, high levels of NT-proBNP and low levels of HDL cholesterol were associated with increased 30-day mortality.

Mortality after osteoporotic hip fracture: incidence, trends, and associated factors

BACKGROUND

It is known that mortality after hip fracture increases compared to the general population; the trend in mortality is a controversial issue. The objective of this study is to examine incidence, trends, and factors associated with mortality in patients with osteoporotic hip fractures.

METHODS

This is a retrospective cohort study that uses the Registry for Hospital Discharges of the National Health System of our hospital. Patients older than 45 having an osteoporotic hip fracture between 1999 and 2015 were identified. Demographic data and comorbidities were obtained. A survival analysis was performed (Cox regression and Kaplan-Meier). Incidence rate, standardized death rate (SDR), trend (Poisson regression), and risk (hazard ratio) were calculated.

RESULTS

During 1999-2015, in our hospital, there were a total of 3992 patients admitted due to osteoporotic hip fracture. Out of these 3992 patients, 3109 patients (77.9%) were women with an average age of 84.47 years (SD 8.45) and 803 (22.1%) were men with an average age of 81.64 years (SD 10.08). The cumulative incidence of mortality was 69.38%. The cumulative mortality rate for 12 months was 33%. The annual mortality was 144.9/1000 patients/year. The 1-year mortality rate increased significantly by 2% per year (IRR 1.020, CI95% 1.008-1.033). The median overall survival was 886 days (CI95% 836-951). The probability of mortality density for a period of 10 years following a hip fracture was 16% for women and 25% for men (first 90 days). The SDR was 8.3 (CI95% 7.98-8.59). Variables that showed statistically significant association with mortality were aged over 75, masculine, institutionalization, mild to severe liver disease, chronic kidney disease, COPD, dementia, heart failure, diabetes, the Charlson Index > 2 , presence of vision disorders and hearing impairment, incontinence, and Downton scale.

CONCLUSIONS

For the last 17 years, an increase of mortality for patients with hip fracture and a higher mortality rate in men than in women were observed. Institutionalization combined with comorbidities is associated with a higher mortality.

Outcome of non-surgical treatment of proximal femur fractures in the fragile elderly population

INTRODUCTION

With the aging of the population the rate of fragility hip fractures increases. While medical recommendations are for hasten surgical treatment, for some older patients burdened with severe comorbidities, this might be risky.

AIMS

To compare the outcomes of patients treated non-surgically to those of the most fragile patients treated surgically.

PATIENTS AND METHODS

A retrospective cohort study, of individuals aged ≥65 years who presented with fragility hip fractures between 01.01.2011-30.06.2016, to a primary trauma center. Patients treated surgically were stratified according to their age-adjusted Charlsons' comorbidity index (ACCI) score. Patients in the upper third of ACCI score, representing the more fragile population, were compared to patients treated non-surgically.

RESULTS

847 patients presented with fragility fractures. 94 (11%) were treated non-surgically and 753 (89%) underwent surgery. Medical reasons were the leading cause for non-surgical treatment (61.7%). Surgically-treated patients were stratified according to their ACCI and 114 patients with ACCI > 9 were chosen for comparison. While both groups were comparable in terms of age, the non-surgical treatment group had more female patients (p. = 0.026) and a smaller proportion of independent walkers (p < 0.001). The ACCI was higher for the surgical treatment group (p < 0.001). In-hospital mortality was similar (14.9% and 18.1% for the operative and non-surgical groups respectively, P. = 0.575). However, one-year mortality was significantly higher for the non-surgical group (48.2% vs. 67.0%, P. = 0.005). The rates of in-hospital complications and 1-year readmissions were similar.

CONCLUSIONS

Operative treatment for fragility hip fracture reduces long-term mortality rates even in the more fragile patients, compared to non-surgical treatment.

Risk of institutionalization following fragility fractures in older people

Previously independent living older people suffering fractures of the hip have a high risk of new admission to a nursing home during the subsequent months. This study shows that older people admitted to hospital for fractures of the pelvis and spine have a similar risk of admission to a nursing home.

INTRODUCTION

Fall-related fractures are a serious threat to the health and well-being of older persons. Long-term consequences of hip fractures such as institutionalization and mortality are well-known. The impact of other fragility fractures is less well-understood. The aim of this study was to estimate risks of institutionalization and death for different fragility fractures and compare them with the corresponding risks after hip fracture.

METHODS

Data was retrieved from a German health insurance company. Between 2005 and 2008 more than 56,000 community-dwelling people with a hospital admission or discharge diagnosis of a fracture of the femur, spine, pelvis, proximal humerus, distal radius, tibia, or fibula were included. Crude and age-adjusted 6-month incidence rates for institutionalization and death were calculated. To compare the risks of institutionalization or mortality of non-hip fractures with the risk after hip fracture, multivariate regression models were applied.

RESULTS

Crude institutionalization rates and mortality were highest in patients with hip fracture. However, after adjustment for age, functional status, and comorbidity, risks of institutionalization after fractures of pelvis (relative risk (RR), 0.94; 95% confidence interval (CI) 0.86; 1.02 in women and 0.89; 95% CI 0.70; 1.12 in men), and spine (RR, 0.95; 95% CI 0.87; 1.03 in women and 0.91; 95% CI 0.76; 1.08 in men) were not statistically different compared to the risk after hip fracture.

CONCLUSIONS

The risk of institutionalization after fractures of the spine and pelvis was similar to the risk after hip fracture. These fracture sites seem to be associated with a significant decline in physical function.

Use of antiosteoporotic drugs and calcium/vitamin D in patients with fragility fractures: impact on re-fracture and mortality risk

PURPOSE

To evaluate the impact of pharmacological treatment in osteoporosis patients with recent fracture and to assess the incidence of subsequent fracture and all-cause mortality.

METHODS

This observational retrospective study was based on data from administrative databases of five Italian Local Health Units. Osteoporosis patients aged ≥ 50 years with hospitalization for vertebral or hip fracture occurring between 01/01/2011 and 31/12/2015 were included. Treatment adherence was calculated using the medication possession ratio. Multivariable proportional hazard Cox model was used to identify factors associated with time to re-fracture and all-cause mortality.

RESULTS

A cohort of 3475 patients were included and 41.5% of them did not receive any specific anti-fracture treatment. Among treated patients (N = 2032), the majority (83.6%) received calcium/vitamin D supplementation. Over a mean follow-up of 3 years, the risk of subsequent fractures was 44.4% lower in treated patients compared to untreated ones (HR = 0.556, 95% CI = 0.420-0.735, p < 0.001) and 64.4% lower in those receiving calcium/vitamin D supplementation compared to osteoporosis treatment only (HR = 0.356, 95% CI = 0.237-0.533, p < 0.001). The risk of re-fracture was 77.2% lower in treated patients who were adherent to medication (HR = 0.228, 95% CI = 0.139-0.376, p < 0.001). Treated patients had 64% lower mortality risk over the follow-up compared to untreated ones (HR = 0.360, 95% CI = 0.310-0.418, p < 0.001).

CONCLUSIONS

A consistent proportion of osteoporosis patients did not receive specific treatment after a fracture, showing poor adherence to national guidelines on osteoporosis treatment. Osteoporosis drug treatment, and to a greater extent in combination with calcium/vitamin D, and adherence were correlated with lower risk of both re-fracture and all-cause mortality.

Inflammatory cytokines IL-6 and TNF-α in patients with hip fracture

Mortality and remaining bedridden following the hip fracture surgery are not rare. We tried to measure the levels of inflammatory markers tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) following the hip fracture surgery and compare their levels with controls. We aimed to show a relationship between the levels of these markers and post-operative mortality and walking capability.

INTRODUCTION

Osteoporosis is a condition, causing the hip fractures in the elderly. Hip fractures have a high rate of overall mortality up to 30% following the incident. Cytokines such as IL-6 and TNF-α are suggested to play a role in bone resorption and, thus, in the etiology of osteoporosis.

METHODS

Plasma levels of IL-6 and TNF-α were measured pre-operatively and on the first and second days after the surgery in 40 Turkish hip fracture patients. The levels of these cytokines were compared with 40 Turkish age-matched healthy controls. The levels of these cytokines were compared between the deceased and surviving patients, as well as the existence of walking capability following the surgery.

RESULTS

Significantly higher IL-6 levels were shown on the first and second days after the surgery (p = 0.005; p = 0.01, respectively). The overall death rate of our study group within the 2-year follow-up time was found to be 35%. No statistical significance was found in the means of 2-year follow-up mortality between the patients. Presence of walking capability did not differ between the patients, as well.

CONCLUSION

We demonstrated an association between IL-6 levels and hip fracture in our study group following the surgery. We also suggest that TNF-α and IL-6 levels are not related to the occurrence of death and walking capability after the surgery. However, these findings need further functional and clinical confirmation.

Mortality risk reduction differs according to bisphosphonate class: a 15-year observational study

In this prospective cohort of 6120 participants aged 50+, nitrogen-bisphosphonates but not non-nitrogen bisphosphonates were associated with a significant 34% mortality risk reduction compared to non-treated propensity score matched controls. These findings open new avenues for research into mechanistic pathways.

INTRODUCTION

Emerging evidence suggests that bisphosphonates (BP), first-line treatment of osteoporosis, are associated with reduced risks for all-cause mortality. This study aimed to determine the association between different BP types and mortality risk in participants with or without a fracture.

METHODS

A prospective cohort study of users of different BPs matched to non-users by propensity score (age, gender, co-morbidities, fragility fracture status) and time to starting the BP medication from the population-based Canadian Multicentre Osteoporosis Study from nine Canadian centres followed from 1995 to 2013. Mortality risk for bisphosphonate users vs matched non-users was assessed using pairwise multivariable Cox proportional hazards models.

RESULTS

There were 2048 women and 308 men on BP and 1970 women and 1794 men who did not receive medication for osteoporosis. The relationship between BP and mortality risk was explored in three separate 1:1 propensity score-matched cohorts of BP users and no treatment (etidronate, n = 599, alendronate, n = 498, and risedronate n = 213). Nitrogen BP (n-BP) (alendronate and risedronate) was associated with lower mortality risks [pairwise HR, 0.66 (95% CI, 0.48-0.91)] while the less potent non-n-BP, etidronate, was not [pairwise HR: 0.89 (95% CI, 0.66-1.20)]. A direct comparison between n-BP and etidronate (n = 340 pairs) also suggested a better survival for n-BP [paired HR, 0.47 (95%CI, (95% CI, 031-0.70)] for n-BP vs. etidronate].

CONCLUSION

Compared to no treatment, nitrogen but not non-nitrogen bisphosphonates appear to be associated with better survival.

Preoperative antithrombotic therapy and risk of blood transfusion and mortality following hip fracture surgery: a Danish nationwide cohort study

Hip fracture surgery is associated with high risk of bleeding and mortality. The patients often have cardiovascular comorbidity, which requires antithrombotic treatment. This study found that preoperative use of oral anticoagulants was not associated with transfusion or mortality following hip fracture surgery, whereas increased risk may exist for antiplatelet drugs.

INTRODUCTION

Hip fracture surgery is associated with high bleeding risk and mortality; however, data on operative outcomes of hip fracture patients admitted while on antithrombotic therapy is sparse. We examined if preoperative antithrombotic treatment was associated with increased use of blood transfusion and 30-day mortality following hip fracture surgery.

METHODS

Using data from the Danish Multidisciplinary Hip Fracture Registry, we identified 74,791 hip fracture surgery patients aged ≥ 65 years during 2005-2016. Exposure was treatment with non-vitamin K antagonist oral anticoagulant (NOAC), vitamin K antagonists (VKA), or antiplatelet drugs at admission for hip fracture. Outcome was blood transfusion within 7 days postsurgery and death within 30 days.

RESULTS

A 45.3% of patients received blood transfusion and 10.6% died. Current NOAC use was associated with slightly increased risk of transfusion (adjusted relative risk (aRR) 1.07, 95% confidence interval (CI) 1.01-1.14), but similar mortality risk (adjusted hazard ratio (aHR) 0.88, 95% CI 0.75-1.03) compared with non-users. The pattern remained when restricting to patients with short surgical delay (< 24 h). VKA users did not have increased risk of transfusion or mortality. The risks of transfusion (aRR 1.15 95% CI 1.12-1.18) and 30-day mortality (aHR 1.18 95% CI 1.14-1.23) were increased among antiplatelet users compared with non-users.

CONCLUSIONS

In an observational setting, neither preoperative NOAC nor VKA treatments were associated with increased risk of 30-day postoperative mortality among hip fracture patients. NOAC was associated with slightly increased risk of transfusion. Preoperative use of antiplatelet drugs was associated with increased risk of transfusion and mortality.

All-cause mortality with current and past use of antidepressants or benzodiazepines after major osteoporotic and hip fracture

In the first year, after an osteoporotic fracture of a hip, forearm, upper arm, or spine, the dispensing rates of antidepressants and benzodiazepines increased significantly. After those fractures, recent and past use of antidepressants and benzodiazepines was associated with increased all-cause mortality; current use was not associated with mortality risk.

INTRODUCTION

It remains unclear to what extent use of antidepressants and benzodiazepines is associated with mortality risk after a major osteoporotic fracture (MOF). We aimed to study the cumulative use of antidepressants and benzodiazepines during the year after MOF or hip fracture (HF) and whether the use was associated with mortality.

METHODS

A cohort study was performed within the Dutch PHARMO Database Network including all patients aged 65+ with a first record of MOF (hip, humerus, forearm, and clinical vertebral fracture) between 2002 and 2011. Data were analyzed using Cox regression models, adjusted for comorbidities, and concomitant medication use and broken down to index fracture type.

RESULTS

A total of 4854 patients sustained a first MOF, of whom 1766 patients sustained a HF. Mean follow-up was 4.6 years, divided in 30-day periods. The cumulative antidepressant and benzodiazepine use during the first year after MOF increased from 10.6 to 14.7% and from 24.0 to 31.4%, respectively. Recent (31-92 days before each follow-up period) and past use (> 92 days before) of antidepressants and benzodiazepines after MOF or HF was associated with an increased all-cause mortality risk but current use (< 30 days before) was not.

CONCLUSION

There is a considerable increase in dispensing rate of antidepressants and benzodiazepines in the first year after a MOF. Recent and past use of these medications was associated with all-cause mortality. The finding that current use was not associated with mortality should be further explored and may probably be explained by the healthy survivor's bias.

Does a dedicated hip fracture unit improve clinical outcomes? A five-year case series

INTRODUCTION

The aim of the study was to establish whether a dedicated hip fracture unit, geographically separate from the local major trauma centre, could improve clinical outcomes for patients sustaining proximal femoral fragility fractures.

MATERIALS AND METHODS

This study was a retrospective case series, using data collected from Brighton and Sussex University Hospitals NHS Trust's submissions to the National Hip Fracture Database between 1 April 2011 and 16 September 2016. The outcomes measured were mortality, length of hospital stay, time from admission to surgical intervention and return to premorbid residence. Patients were compared before and after reconfiguration of services into a separate dedicated hip fracture unit geographically distinct from the major trauma centre.

RESULTS

A total of 2117 patients (2178 injuries) were managed before the existence of the hip fracture unit, while 660 patients (673 injuries) were treated within the hip fracture unit. During the five-year study period, the 30-day mortality rate (pre-hip fracture unit 5.47% vs hip fracture unit 3.13%, P = 0.014), variance in the length of hospital stay (P < 0.001), mean time to surgical intervention (P = 0.044) and return to premorbid residence were significantly improved. An immediate 12-month comparison demonstrated significantly improved variance in length of hospital stay (P = 0.020) and return to premorbid residence (P = 0.015).

DISCUSSION

The reconfiguration of services significantly reduced variance in length of stay, enabling accurate resource planning in future. Multiple incremental improvements in service provision, in addition to the hip fracture unit, may explain the lower mortality observed.

CONCLUSION

While further research is required, replication of the hip fracture unit service model may potentially afford significant clinical and financial gains.

Association of Back Pain with All-Cause and Cause-Specific Mortality Among Older Women: a Cohort Study

BACKGROUND

The impact of back pain on disability in older women is well-understood, but the influence of back pain on mortality is unclear.

OBJECTIVE

To examine whether back pain was associated with all-cause and cause-specific mortality in older women and mediation of this association by disability.

DESIGN

Prospective cohort study.

SETTING

The Study of Osteoporotic Fractures.

PARTICIPANTS

Women aged 65 or older.

MEASUREMENT

Our primary outcome, time to death, was assessed using all-cause and cause-specific adjusted Cox models. We used a four-category back pain exposure (no back pain, non-persistent, infrequent persistent, or frequent persistent back pain) that combined back pain frequency and persistence across baseline (1986-1988) and first follow-up (1989-1990) interviews. Disability measures (limitations of instrumental activities of daily living [IADL], slow chair stand time, and slow walking speed) from 1991 were considered a priori potential mediators.

RESULTS

Of 8321 women (mean age 71.5, SD = 5.1), 4975 (56%) died over a median follow-up of 14.1 years. A higher proportion of women with frequent persistent back pain died (65.8%) than those with no back pain (53.5%). In the fully adjusted model, women with frequent persistent back pain had higher hazard of all-cause (hazard ratio [HR] = 1.24 [95% CI, 1.11-1.39]), cardiovascular (HR = 1.34 [CI, 1.12-1.62]), and cancer (HR = 1.33, [CI 1.03-1.71]) mortality. No association with mortality was observed for other back pain categories. In mediation analyses, IADL limitations explained 47% of the effect of persistent frequent back pain on all-cause mortality, slow chair stand time, and walking speed, explained 27% and 24% (all significant, p < 0.001), respectively.

LIMITATIONS

Only white women were included.

CONCLUSION

Frequent persistent back pain was associated with increased mortality in older women. Much of this association was mediated by disability.

Prediction of the Mortality with Comorbidity - Polypharmacy Score in the Osteoporotic Hip Fractures

PURPOSE OF THE STUDY Osteoporotic hip fractures commonly associated with comorbid diseases and use of multiple drugs. Polypharmacy status and the comorbidity-polypharmacy score (CPS) are the most common two grading system to predict mortality risk for the trauma patients older than 45 years. The purpose of the study was to determine whether the CPS or polypharmacy can predict the mortality risk in the older patients had a surgery due to an osteoporotic hip fracture. MATERIAL AND METHODS Consecutive patients aged > 65 years had an osteoporotic hip fracture due to a simple trauma were enrolled in the study. Detailed data were collected included comorbid conditions, medications, T-scores and additional fractures. Patients were divided into four groups according to CPS classification and polypharmacy status was indicated in case of using five or more drugs before admission. Overall mortality was assessed using Kaplan-Meier survival testing. Factors influencing 1-year, 2-year and 5-year mortality were evaluated using a multivariate logistic regression model with adjusted odds ratios (AORs) and a threshold significance at p < 0.05. RESULTS A total of 109 patients (65% women) with a mean age 80 ± 8.06 were included in the study. The mean time to death from the surgery was 42.06 ± 34.9 months. The Kaplan-Meier survival curves showed a significant difference in mortality among CPS groups. (Log-Rank test < 0.001). CPS presented a significant prediction in 1-year (AOR: 4.2; p < 0.05) and 2-year mortality (AOR: 2.9; p < 0.05) after adjustment for several covariates (including age, gender, surgical procedure) whereas 5-year mortality did not reveal a significant prediction (p = 0.46) Polypharmacy existence did not independently predict both overall or year-based mortality (p > 0.05) . CONCLUSIONS CPS is a better predictor for mortality risk than polypharmacy existence in the first two years in the patients underwent surgery for an osteoporotic hip fracture. Key words:osteoporotic hip fracture, mortality, polypharmacy, comorbidity.

Length of hospital stay after hip fracture surgery and 1-year mortality

There is ongoing effort to discharge patients early after hip fracture surgery to reduce the medical and economic burden. We tried to find whether there is any related side effect, and discovered that early discharge, especially before 10 days after surgery, is associated with higher mortality.

INTRODUCTION

The aim of this study was to analyze the association between the length of hospital stay after hip fracture and 1-year mortality in older adults aged ≥ 65 years old.

METHODS

We conducted a retrospective cohort study using the Korean National Health Insurance Service data to identify patients who were discharged after hip fracture surgery from 2007 to 2009 among 487,460 older adults of age ≥ 65 years. The lengths of stay involving hip fracture surgery were categorized at 10-day interval, and analyzed in relation to 1-year mortality from the date of hospital discharge.

RESULTS

A total of 4213 patients were discharged after hip fracture surgery, of whom 604 (14.3%) died within 1 year of discharge. The average length of stay was 30.7 days (standard deviation 24.5 days). The 1-year mortality was the highest for the length of stay ≤ 10 days group at 21.7%, followed by 15.2%, 14.3%, 13.3%, and 12.4% for > 40, 21-30, 31-40, and 11-20 days groups, respectively (p value 0.05). On Cox proportional hazard regression, the adjusted hazard ratio for length of stay ≤ 10 days group was 1.56 (95% confidence interval 1.14-2.12) against the reference group (11-20 days), while other groups did not show statistical significance. Higher risk of death was associated with increasing age, male gender, Charlson comorbidity index ≥3, subtrochanteric fracture, and discharge to tertiary care hospitals and long-term care hospitals.

CONCLUSION

Older adults discharged within 10 days of hospital admission for hip fracture surgery have higher 1-year mortality after discharge.

Osteoporosis and osteopenia in the distal forearm predict all-cause mortality independent of grip strength: 22-year follow-up in the population-based Tromsø Study

Low bone mineral density (BMD) gives an increased risk of fractures, which can lead to premature death. Can BMD of the wrist predict mortality? BMD consistent with osteopenia and osteoporosis gave a significantly increased risk of death for both men and women in a general population in Tromsø, Norway.

INTRODUCTION

To investigate if bone mineral density (BMD) levels of the distal forearm, consistent with osteopenia and osteoporosis, can predict mortality and if grip strength is an effect modifier.

METHODS

The study population constituted 6565 participants aged 50-79 years at baseline in the Tromsø Study wave 4 conducted in 1994-1995. Forearm BMD measured by SXA was categorized as "normal," "osteopenia," or "osteoporosis" following WHO's definition. Cox regression with all-cause mortality as the outcome over 22 years of follow-up was performed for men and women separately, adjusting for health-related factors, as well as BMD by grip strength interaction. A secondary analysis with a 15-year follow-up also adjusted for hip fractures and osteoporotic fractures.

RESULTS

During follow-up, 3176 of participants died (47%). Those categorized as osteoporotic had higher mortality hazard ratio (HR) compared to those with normal BMD; men HR = 1.37 (95% confidence interval (CI) 1.19, 1.58) and women HR = 1.32 (1.14, 1.53) were adjusted for age, body mass index, physical activity, smoking habits, education, health status, chronic diseases, and grip strength. Corresponding HRs for osteopenia were men HR = 1.13 (1.00, 1.27) and women HR = 1.17 (1.01, 1.35). Further adjustments for fractures did only marginally attenuate the results, and HRs were still significant. There was no grip strength by BMD interaction.

CONCLUSION

Men and women with low distal forearm BMD values, consistent with osteoporosis or osteopenia, had an increased mortality compared to normal BMD participants. High grip strength did not modify this association, and the association remained after adjustment for a range of health-related factors.

Volumetric bone mineral density of the spine predicts mortality in African-American men with type 2 diabetes

The study showed that in African-American men with type 2 diabetes mellitus (T2D), vertebral volumetric bone mineral density (vBMD) predicts all-cause mortality, independent of other risk factors for death.

INTRODUCTION

Compared to European Americans, African Americans have lower rates of osteoporosis and higher rates of T2D. The relationships between BMD and fractures with mortality are unknown in this population. The aim of this study was to determine relationships between vertebral fractures and vertebral vBMD and mortality in African Americans with T2D.

METHODS

Associations between vertebral fractures and vBMD with all-cause mortality were examined in 675 participants with T2D (391 women and 284 men) in the African American-Diabetes Heart Study (AA-DHS). Lumbar and thoracic vBMD were measured using quantitative computed tomography (QCT). Vertebral fractures were assessed on sagittal CT images. Associations of vertebral fractures and vBMD with all-cause mortality were determined in sex-stratified analyses and in the full sample. Covariates in a minimally adjusted model included age, sex, BMI, smoking, and alcohol use; the full model was adjusted for those variables plus cardiovascular disease, hypertension, coronary artery calcified plaque, hormone replacement therapy (women), African ancestry proportion, and eGFR.

RESULTS

After mean 7.6 ± 1.8-year follow-up, 59 (15.1%) of women and 58 (20.4%) of men died. In men, vBMD was inversely associated with mortality in the fully adjusted model: lumbar hazard ratio (HR) per standard deviation (SD) = 0.70 (95% CI 0.52-0.95, p = 0.02) and thoracic HR per SD = 0.71 (95% CI 0.54-0.92, p = 0.01). Only trends toward association between vBMD and mortality were observed in the combined sample of men and women, as significant associations were absent in women. Vertebral fractures were not associated with mortality in either sex.

CONCLUSIONS

Lower vBMD was associated with increased all-cause mortality in African-American men with T2D, independent of other risk factors for mortality including subclinical atherosclerosis.

Persistence of Excess Mortality Following Individual Nonhip Fractures: A Relative Survival Analysis

CONTEXT

Little is known about long-term excess mortality following fragility nonhip fractures.

OBJECTIVE

The study aimed to determine which fracture was associated with excess mortality and for how long the postfracture excess mortality persisted.

DESIGN, SETTING, AND PATIENTS

This nationwide registry-based follow-up study included all individuals in Denmark aged 50+ years who first experienced fragility fractures in 2001 and were followed up for up to 10 years for their mortality risk.

MAIN OUTCOME MEASURE

The contribution of fracture to mortality at precise postfracture time intervals was examined using relative survival analysis, accounting for time-related mortality changes in the background population.

RESULTS

There were 21,123 women (aged 72 ± 13 years) and 9481 men (aged 67 ± 12 years) with an incident fragility fracture in 2001, followed by 10,668 and 4745 deaths, respectively. Excess mortality was observed following all proximal and lower leg fractures. The majority of deaths occurred within the first year after fracture, and thereafter excess mortality gradually declined. Hip fractures were associated with the highest excess mortality (33% and 20% at 1 year after fracture in men and women, respectively). One-year excess mortality after fracture of a femur or pelvis was 20% to 25%; vertebrae, 10%; humerus, rib, or clavicle, 5% to 10%; and lower leg, 3%. A significant although smaller excess mortality was still observed until 10 years for hip fractures and ~5 years after femur, other proximal, and lower leg fractures.

CONCLUSION

This study highlights the important contribution of a wide variety of fragility fractures to long-term excess mortality and thus the potential for benefit from early intervention.

Fracture liaison services improve outcomes of patients with osteoporosis-related fractures: A systematic literature review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis evaluated the outcomes of patients with osteoporosis-related fractures managed through fracture liaison services (FLS) programs.

METHODS

Medline, PubMed, EMBASE, and the Cochrane Library were searched (January 2000-February 2017 inclusive) using the keywords 'osteoporosis', 'fractures', 'liaison', and 'service' to identify randomised controlled trials and observational studies of patients aged ≥50years with osteoporosis-related fractures in hospital, clinic, community, or home-based settings who were managed using FLS. Risk of bias was assessed at outcome level. Meta-analysis followed a random-effects and fixed-effects model. Outcomes of interest were incidence of bone mineral density (BMD) testing, treatment initiation, adherence, re-fractures, and mortality due to osteoporosis treatment.

RESULTS

A total of 159 publications were identified for the systematic literature review; 74 controlled studies (16 RCTs; 58 observational studies) were included in the meta-analysis. Overall, 41 of 58 observational studies and 12 of 16 RCTs were considered of high quality. Compared with patients receiving usual care (or those in the control arm), patients receiving care from an FLS program had higher rates of BMD testing (48.0% vs 23.5%) and treatment initiation (38.0% vs 17.2%) and greater adherence (57.0% vs 34.1%). Unweighted average rates of re-fracture were 13.4% among patients in the control arm and 6.4% in the FLS arm. Unweighted average rates of mortality were 15.8% in the control arm and 10.4% in the FLS arm. Meta-analysis revealed significant FLS-associated improvements in all outcomes versus non-FLS controls, with BMD testing increased by 24 percentage points (95% confidence interval [CI] 0.18-0.29), 20 percentage points for treatment rates (95% CI 0.16-0.25), and 22 percentage points for adherence (95% CI 0.13-0.31) and absolute risk of re-fracture reduced by five percentage points (95% CI -0.08 to -0.03) and mortality reduced by three percentage points (95% CI -0.05 to -0.01).

CONCLUSION

FLS programs improved outcomes of osteoporosis-related fractures, with significant increases in BMD testing, treatment initiation, and adherence to treatment and reductions in re-fracture incidence and mortality.

Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?

The 5-year period following 2009 saw a steep reduction in vertebral augmentation volume and was associated with elevated mortality risk in vertebral compression fracture (VCF) patients. The risk of mortality following a VCF diagnosis was 85.1% at 10 years and was found to be lower for balloon kyphoplasty (BKP) and vertebroplasty (VP) patients.

INTRODUCTION

BKP and VP are associated with lower mortality risks than non-surgical management (NSM) of VCF. VP versus sham trials published in 2009 sparked controversy over its effectiveness, leading to diminished referral volumes. We hypothesized that lower BKP/VP utilization would lead to a greater mortality risk for VCF patients.

METHODS

BKP/VP utilization was evaluated for VCF patients in the 100% US Medicare data set (2005-2014). Survival and morbidity were analyzed by the Kaplan-Meier method and compared between NSM, BKP, and VP using Cox regression with adjustment by propensity score and various factors.

RESULTS

The cohort included 261,756 BKP (12.6%) and 117,232 VP (5.6%) patients, comprising 20% of the VCF patient population in 2005, peaking at 24% in 2007-2008, and declining to 14% in 2014. The propensity-adjusted mortality risk for VCF patients was 4% (95% CI, 3-4%; p < 0.001) greater in 2010-2014 versus 2005-2009. The 10-year risk of mortality for the overall cohort was 85.1%. BKP and VP cohorts had a 19% (95% CI, 19-19%; p < 0.001) and 7% (95% CI, 7-8%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the NSM cohort, respectively. The BKP cohort had a 13% (95% CI, 12-13%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the VP cohort.

CONCLUSIONS

Changes in treatment patterns following the 2009 VP publications led to fewer augmentation procedures. In turn, the 5-year period following 2009 was associated with elevated mortality risk in VCF patients. This provides insight into the implications of treatment pattern changes and associated mortality risks.

Characteristics and outcomes of hospitalised patients with vertebral fragility fractures: a systematic review

Background

the complex management for patients presenting to hospital with vertebral fragility fractures provides justification for the development of specific services for them. A systematic review was undertaken to determine the incidence of hospital admission, patient characteristics and health outcomes of vertebral fragility fracture patients to inform the development of such a service.

Methods

non-randomised studies of vertebral fragility fracture in hospital were included. Searches were conducted using electronic databases and citation searching of the included papers.

Results

a total of 19 studies were included. The incidence of hospital admission varied from 2.8 to 19.3 per 10,000/year. The average patient age was 81 years, the majority having presented with a fall. A diagnosis of osteoporosis or previous fragility fracture was reported in around one-third of patients. Most patients (75% men and 78% women) had five or more co-pathologies. Most patients were managed non-operatively with a median hospital length of stay of 10 days. One-third of patients were started on osteoporosis treatment. Inpatient and 1-year mortality was between 0.9 and 3.5%, and 20 and 27%, respectively, between 34 and 50% were discharged from hospital to a care facility. Many patients were more dependent with activities of daily living on discharge compared to their pre-admission level. Older age and increasing comorbidities was associated with longer hospital stay and higher mortality.

Conclusion

these findings indicate that specific hospital services for patients with vertebral fragility fractures should take into consideration local hospitalisation rates for the condition, and should be multifaceted-providing access to diagnostic, therapeutic, surgical and rehabilitation interventions.

Which Sleep Health Characteristics Predict All-Cause Mortality in Older Men? An Application of Flexible Multivariable Approaches

Study Objectives

Sleep is multidimensional, with domains including duration, timing, continuity, regularity, rhythmicity, quality, and sleepiness/alertness. Individual sleep characteristics representing these domains are known to predict health outcomes. However, most studies consider sleep characteristics in isolation, resulting in an incomplete understanding of which sleep characteristics are the strongest predictors of health outcomes. We applied three multivariable approaches to robustly determine which sleep characteristics increase mortality risk in the osteoporotic fractures in men sleep study.

Methods

In total, 2,887 men (mean 76.3 years) completed relevant assessments and were followed for up to 11 years. One actigraphy or self-reported sleep characteristic was selected to represent each of seven sleep domains. Multivariable Cox models, survival trees, and random survival forests were applied to determine which sleep characteristics increase mortality risk.

Results

Rhythmicity (actigraphy pseudo-F statistic) and continuity (actigraphy minutes awake after sleep onset) were the most robust sleep predictors across models. In a multivariable Cox model, lower rhythmicity (hazard ratio, HR [95%CI] =1.12 [1.04, 1.22]) and lower continuity (1.16 [1.08, 1.24]) were the strongest sleep predictors. In the random survival forest, rhythmicity and continuity were the most important individual sleep characteristics (ranked as the sixth and eighth most important among 43 possible sleep and non-sleep predictors); moreover, the predictive importance of all sleep information considered simultaneously followed only age, cognition, and cardiovascular disease.

Conclusions

Research within a multidimensional sleep health framework can jumpstart future research on causal pathways linking sleep and health, new interventions that target specific sleep health profiles, and improved sleep screening for adverse health outcomes.

Mortality following benign sacral insufficiency fracture and associated risk factors

This study demonstrated increased mortality following sacral insufficiency fractures as with other major osteoporotic fractures. The 6-month mortality rate was 9.8%, the 1-year mortality rate was 17.5%, and the 3-year mortality rate was 25.5%. Sex- and age-adjusted standardized mortality ratio increased after fractures.

INTRODUCTION

There are no data about mortality after sacral insufficiency fractures. The purposes of this study were to investigate the mortality rate among sacral insufficiency fracture patients and to identify risk factors associated with mortality.

METHODS

This is a retrospective cohort study of patients diagnosed with sacral insufficiency fracture via radiological exam in a single institute from 2001 to 2014, excluding patients with pathological sacral fracture due to metastasis or primary tumor. Mortality and its predisposing factors were analyzed based on a review of electronic medical records and mortality data provided by the Korean Statistical Information Service. Kaplan-Meier survival analysis and Cox regression analysis were used for statistical analysis.

RESULTS

A total of 325 patients were included (275 women and 50 men). The mean age at the time of diagnosis was 69.4 years. One hundred and forty patients (43.1%) had a history of malignancy, and 71 patients (21.8%) had undergone pelvic radiation therapy before fracture diagnosis. Twenty-one patients (6.5%) underwent sacroplasty, and the others underwent conservative management after fracture diagnosis. The mean follow-up was 51.5 months, and a total of 101 patients died at the final follow-up. The 6-month mortality rate was 9.8%, the 1-year mortality rate was 17.5%, and the 3-year mortality rate was 25.5%. Sex- and age-adjusted standardized mortality ratio (SMR) increased after fractures. The overall SMR is 8.9 at 3 months decreasing to 4.5 at 2 years. Multivariable Cox regression analysis showed that significant factors associated with increased mortality were male gender, malignancy history, lumbosacral fusion with distal fusion level S1, stroke history, low total femur bone mineral density score, and low body mass index.

CONCLUSIONS

Like other types of osteoporotic fractures, sacral insufficiency fractures are associated with increased mortality.

Primary and secondary non-adherence to osteoporotic medications after hip fracture in Spain. The PREV2FO population-based retrospective cohort study

Osteoporotic medication after hip fracture is widely recommended by clinical practice guidelines, and medication adherence is essential to meet clinical trial risk reduction figures in the real world. We assessed primary and secondary non-adherence to osteoporosis medications in patients discharged following a hip fracture and identified factors associated with secondary non-adherence. From a population-based retrospective cohort of 19,405 patients aged 65 years and over discharged from a hip fracture in the region of Valencia (Spain) from January 1, 2008 and June 30, 2012, we followed, over a minimum of 365 days, 4,856 patients with at least one osteoporotic medication prescribed within the first six months after discharge. Less than one third of the patients discharged alive after a hip fracture received osteoporotic treatment. Primary non-adherence among naïve patients was low. However, long-term secondary adherence measured by Proportion of Days Covered with medication (PDC) and persistence was largely suboptimal, with naïve users having worse results than experienced patients. Secondary non-adherence was associated with primary non-adherence and age, dementia or sedative treatments for naïve users and with being male, being older than 85 and having dementia for experienced users. Three quarters of naïve users and two thirds of experienced users had interrupted treatment at 48 months.

Excess of all-cause mortality after a fracture in type 2 diabetic patients: a population-based cohort study

Post-fracture mortality in type 2 diabetes mellitus (T2DM) patients has been poorly studied. We report an absolute and relative excess all-cause mortality following a fracture in these patients compared to non-diabetic patients.

INTRODUCTION

T2DM and osteoporotic fractures are independently associated with a reduced lifespan, but it is unknown if T2DM confers an excess post-fracture mortality compared to non-diabetic fracture patients. We report post-fracture all-cause mortality according to T2DM status.

METHODS

This is a population-based cohort study using data from the SIDIAP database. All ≥50 years old T2DM patients registered in SIDIAP in 2006-2013 and two diabetes-free controls matched on age, gender, and primary care center were selected. Study outcome was all-cause mortality following incident fractures. Participants were followed from date of any fracture (AF), hip fracture (HF), and clinical vertebral fracture (VF) until the earliest of death or censoring. Cox regression was used to calculate mortality according to T2DM status after adjustment for age, gender, body mass index, smoking, alcohol intake, and previous ischemic heart and cerebrovascular disease.

RESULTS

We identified 166,106 T2DM patients and 332,212 non-diabetic, of which 11,066 and 21,564, respectively, sustained a fracture and were then included. Post-fracture mortality rates (1000 person-years) were (in T2DM vs non-diabetics) 62.7 vs 49.5 after AF, 130.7 vs 112.7 after HF, and 54.9 vs 46.2 after VF. Adjusted HR (95% CI) for post-AF, post-HF, and post-VF mortality was 1.30 (1.23-1.37), 1.28 (1.20-1.38), and 1.20 (1.06-1.35), respectively, for T2DM compared to non-diabetics.

CONCLUSIONS

T2DM patients have a 30% increased post-fracture mortality compared to non-diabetics and a remarkable excess in absolute mortality risk. More research is needed on the causes underlying such excess risk, and on the effectiveness of measures to reduce post-fracture morbi-mortality in T2DM subjects.

The role of adipokines as prognostic factors of one-year mortality in hip fracture patients

This study investigated the impact of anthropometric parameters, adiponectin, leptin, homeostatic model assessment for insulin resistance (HOMA-IR), beta-isomerised C-terminal telopeptide of collagen type I (β-CTX), and routine biochemical tests on one-year mortality in hip fracture patients. We found that male patients with high adiponectin, leptin, and β-CTX levels had a 5-fold increase in all-cause one-year mortality.

INTRODUCTION

Several predictors of one-year hip fracture mortality have been identified including advanced age, male sex, low bone mineral density, and preexisting comorbidities. However, the impact of metabolic parameters on hip fracture mortality remains unknown. The aim of this study was to examine the effect of serum leptin and adiponectin levels, as well as other metabolic parameters on all-cause one-year hip fracture mortality.

METHODS

This prospective study included 236 patients of all ages with non-traumatic hip fractures. Anthropometric parameters, adiponectin, leptin, HOMA-IR, β-CTX, and routine biochemical tests were recorded at admission and correlated with one-year mortality by using multivariate Cox proportional hazard models.

RESULTS

The median patient age was 82 (75-87) years, and one-year mortality rate was 28.4%. In univariate analysis, adiponectin, age, β-CTX, and renal function were associated with mortality. However, in a multivariate model, male gender, high β-CTX, adiponectin, and leptin were independently associated with increased mortality. Thus, we constructed a nomogram that included all the latter variables in addition to age. The nomogram predicted mortality with a sensitivity of 74.8% (66.0-82.3) and specificity of 74.4% (57.9-87.0), and had an area under the curve of 0.784. Patients that scored <9.2 had a mortality of 10.1%, while those with >9.2 had a mortality of 49.2% (relative risk 5.4, 95% CI 2.8-10.2, P < 0.001).

CONCLUSION

Male patients with high adiponectin, leptin, and β-CTX levels have a 5-fold increase in all-cause one-year mortality after hip fracture.

Effect of comorbidities on the association between age and hospital mortality after fall-related hip fracture in elderly patients

The relation between age and mortality after hip fracture was analyzed in elderly patients. 5.5% of the 31,884 patients died. Compared to those 65-74 years old, the multivariate OR for mortality for those 75-84 and ≥85 were 2.11 (95% CI: 1.61-2.77) and 4.10 (95% CI: 3.14-5.35).

PURPOSE

To analyze the impact of Elixhauser comorbidities on the relation between age and mortality after hip fracture in elderly patients.

METHODS

Cross-sectional study of the population ≥65 years old hospitalized in Spain in 2013 with a diagnosis of fall-related hip fracture in the Basic Minimum Set Data (BMSD). The impact of Elixhauser comorbidities on the association between mortality and age groups (65-74, 75-84, ≥85) was analyzed by logistic regression models with progressive adjustment for demographic variables and comorbidities introduced individually.

RESULTS

We identified 31,884 patients, 5.5% of which died during hospitalization. Compared with those 65-74 years old, the multivariate OR of mortality for those 75-84 and ≥85 years old decreased from 2.23 (95% CI: 1.71-2.90) and 4.57 (95% CI: 3.54-5.90) to 2.11 (95% CI: 1.61-2.77) and 4.10 (95% CI: 3.14-5.35), respectively after adjustment for comorbidities. The OR of mortality for men was 1.77 (95% CI: 1.58-1.98) compared to women. The comorbidities with higher OR for mortality were congestive heart failure (OR: 3.88; 95% CI: 3.42-4.41), metastasis (OR: 3.44; 95% CI: 2.27-5.20), fluid and electrolyte disorders (OR: 2.95; 95% CI: 2.47-3.52), coagulation deficiencies (OR: 2.87; 95% CI: 2.08-3.96), and liver disease (OR: 2.40; 95% CI: 1.82-3.17).

CONCLUSIONS

The association between age and mortality after hip fracture remains after adjusting for numerous comorbidities. However, some potentially controllable disorders are associated with an increased risk for mortality, thus, improving their management could benefit survival.

Use of proton pump inhibitors and mortality after hip fracture in a nationwide study

We analyzed the association of proton pump inhibitors (PPIs) with mortality after osteoporosis-related hip fracture in Austria. PPIs were associated with reduced 90-day mortality but elevated mortality after half a year when initiated pre-fracture. Inpatients and discharged patients on PPIs showed lowered in-hospital and 90-day mortality, respectively.

INTRODUCTION

We herein investigated use of proton pump inhibitors (PPIs) and mortality among hip fracture patients in a nationwide study in Austria.

METHODS

In this retrospective cohort study, data on use of PPIs were obtained from 31,668 Austrian patients ≥50 years with a hip fracture between July 2008 and December 2010. All-cause mortality in patients without anti-osteoporotic drug treatment who had received their first recorded PPI prescription in the study period either before or after fracture was compared with hip fracture patients on neither PPIs nor anti-osteoporotic medication using logistic and Cox regression analysis.

RESULTS

With PPI use, 90-day mortality was significantly reduced, both at initiation before (OR 0.66; p < 0.0001) and after hip fracture (OR 0.23; p < 0.0001). 90-day mortality was also reduced when PPIs were prescribed not until after discharge from the last recorded hip fracture-related hospital stay (OR 0.49; p < 0.0001) except for patients aged <70 years. In a sub-cohort of patients beginning PPIs during hospital stay, in-hospital mortality (0.2%) was substantially reduced relative to matched control patients (3.5%) (p < 0.0001). Longer-term mortality significantly increased after half a year post-fracture only among those who started PPI prescription before fracture.

CONCLUSIONS

PPI use during and after hospital stay due to hip fracture is associated with a considerable decrease in mortality. These findings could have implications for hip fracture treatment.

The effectiveness of a multidisciplinary hip fracture care model in improving the clinical outcome and the average cost of manpower

After the implementation of the multidisciplinary geriatric hip fracture clinical pathway in 2007, the hospital length of stay and the clinical outcomes improves. Moreover, the cost of manpower for each hip fracture decreases. It proves that this care model is cost-effective.

INTRODUCTION

The objective of this study is to compare the clinical outcomes and the cost of manpower before and after the implementation of the multidisciplinary geriatric hip fracture clinical pathway (GHFCP).

METHODS

The hip fracture data from 2006 was compared with the data of four consecutive years since 2008. The efficiency of the program is assessed using the hospital length of stay. The clinical outcomes include mortality rates and complication rates are compared. Cost of manpower was also analysed.

RESULTS

After the implementation of the GHFCP, the preoperative length of stay shortened significantly from 5.8 days in 2006 to 1.3 days in 2011. The total length of stay in both acute and rehabilitation hospitals were also shortened by 6.1 days and 14.2 days, respectively. The postoperative pneumonia rate also decreased from 1.25 to 0.25%. The short- and long-term mortalities also showed a general improvement. Despite allied health manpower was increased to meet the increased workload, the shortened length of stay accounted for a mark decrease in cost of manpower per hip fracture case.

CONCLUSION

This study proves that the GHFCP shortened the geriatric hip fracture patients' length of stay and improves the clinical outcomes. It is also cost-effective which proves better care is less costly.

High mortality in younger patients with major osteoporotic fractures

Data were gathered with regard to mortality after fractures in 1006 younger patients. Results revealed that major osteoporotic fractures of the hip and humerus and drinking alcohol to excess were related to an increased risk of mortality.

INTRODUCTION

Major osteoporotic fractures are known to be associated with increased mortality in older individuals. It is less clear whether this also applies to younger patients.

METHODS

Date were gathered regarding patient demographics, fracture pattern, mechanism of injury, as well as smoking and alcohol intake at the time of injury in consecutive patients aged between 40 and 55 who presented to a UK trauma centre over a 12-month period. Mortality data was taken from the electronic patient records and was cross referenced with data from the General Registrar Office of Scotland. Cox regression analysis was used to identify independent predictors of mortality after adjusting for confounding factors.

RESULTS

The study cohort consisted of 1006 patients, of which 53% were male. The commonest mechanism of injury was a fall. We obtained complete data regarding mortality for all patients at a median of 5.4 years (inter-quartile range 5.1 to 5.6). During this period, 46 patients were identified as being deceased. The overall standardised mortality ratio for the cohort was substantially increased relative to the age and sex matched general population with a ratio of 3.89 (95% confidence intervals (CI) 1.59 to 6.19). Alcohol excess and fractures involving the humerus and the neck of femur were independent predictors of mortality.

CONCLUSIONS

Young individuals with hip and humerus fractures have a significantly increased mortality risk after their injury relative to the general population. The results of our study suggest that this may be in part due to a high prevalence of alcohol excess.

Excess mortality following hip fracture: impact of self-perceived health, smoking, and body mass index. A NOREPOS study

Self-perceived health, smoking, and body mass index measured years before the hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than subjects who did not fracture.

INTRODUCTION

This study aimed to investigate the impact of pre-fracture self-perceived health, smoking, and body mass index (BMI) on excess post-hip fracture mortality using matched peers without hip fracture as reference.

METHODS

The study was based on the Cohort of Norway (CONOR) consisting of 10 regional health studies (1994-2003) and the NOREPOS hip fracture database (1994-2008). A matched cohort design was used to compare survival between hip fracture patients and subjects without fracture (matched on gender, age at participation in CONOR, and study site). Subjects aged ≥60 years were included. Hazard ratios were estimated using stratified Cox regression. Age-standardized mortality was also calculated.

RESULTS

Overall, hip fracture patients (N = 3177) had a 2.26-fold (95 % CI 2.13, 2.40) increased mortality compared to matched subjects (N = 20,282). The highest excess mortality was found in hip fracture patients reporting poor health (HR 4.08, 95 % CI 3.17, 5.26) and daily smoking (HR 3.25, 95 % CI 2.89, 3.66) and in patients with BMI <18.5 (HR 3.07, 95 % CI 2.11, 4.47) prior to the fracture. However, excess mortality was also observed in hip fracture patients in all other categories of BMI, self-perceived health, and smoking.

CONCLUSIONS

Information on self-perceived health, smoking, and BMI collected years before hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than the matched subjects who did not fracture. This suggests that both pre-fracture health status and factors related to the hip fracture itself might affect post-hip fracture mortality.

Incident fracture associated with increased risk of mortality even after adjusting for frailty status in elderly Japanese men: the Fujiwara-kyo Osteoporosis Risk in Men (FORMEN) Cohort Study

Frail elderly individuals have elevated risks of both fracture and mortality. We found that incident fractures were associated with an increased risk of death even after adjusting for pre-fracture frailty status as represented by physical performance tests and laboratory tests for common geriatric diseases in community-dwelling elderly Japanese men.

INTRODUCTION

While fractures reportedly increase the risk of mortality, frailty may complicate this association, generating a false-positive result. We evaluated this association after adjusting for pre-fracture levels of frailty.

METHODS

We examined 1998 community-dwelling ambulatory men aged ≥65 years at baseline in the Fujiwara-kyo Osteoporosis Risk in Men Study for frailty status as represented by activities of daily living (ADL), physical performance tests (grip strength, one-foot standing balance with eyes open, timed 10-m walk), and laboratory sera tests. Participants were then followed for 5 years for incident clinical fractures and death. Effects of incident fracture on death were determined by Cox proportional hazards model with the first fracture during follow-up as a time-dependent predictor and with frailty status indices as covariates.

RESULTS

We identified 111 fractures in 99 men and 138 deaths during the follow-up period (median follow-up, 4.5 years). Participants with incident fractures did not have significantly worse frailty statuses, but did show a significantly higher cumulative mortality rate than those without fractures (p = 0.0047). Age-adjusted hazard ratio (HR) of death for incident fracture was 3.57 (95 % confidence interval: 2.05, 6.24). When adjusted for physical performance, this decreased to 2.77 (1.51, 5.06), but remained significant. The HR showed no significant change when adjusted for laboratory test results (3.96 (2.26, 6.94)). Exclusion of deaths within the first 24 months of follow-up did not alter these results.

CONCLUSION

Incident clinical fracture was associated with an elevated risk of death independently of pre-fracture levels of frailty in community-dwelling elderly men.

Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment

To improve the quality of care and reduce the healthcare costs of elderly patients with a hip fracture, surgeons and geriatricians collaborated intensively due to the special needs of these patients. After treatment at the Centre for Geriatric Traumatology (CvGT), we found a significant decrease in the 1-year mortality rate in frail elderly patients compared to the historical control patients who were treated with standard care.

INTRODUCTION

The study aimed to evaluate the effect of an orthogeriatric treatment model on elderly patients with a hip fracture on the 1-year mortality rate and identify associated risk factors.

METHODS

This study included patients, aged 70 years and older, who were admitted with a hip fracture and treated in accordance with the integrated orthogeriatric treatment model of the CvGT at the Hospital Group Twente (ZGT) between April 2008 and October 2013. Data registration was carried out by several disciplines using the clinical pathways of the CvGT database. A multivariate logistic regression analysis was used to identify independent risk factors for 1-year mortality. The outcome measures for the 850 patients were compared with those of 535 historical control patients who were managed under standard care between October 2002 and March 2008.

RESULTS

The analysis demonstrated that the 1-year mortality rate was 23.2 % (n = 197) in the CvGT group compared to 35.1 % (n = 188) in the historical control group (p < 0.001). Independent risk factors for 1-year mortality were male gender (odds ratio (OR) 1.68), increasing age (OR 1.06), higher American Society of Anesthesiologists (ASA) score (ASA 3 OR 2.43, ASA 4-5 OR 7.05), higher Charlson Comorbidity Index (CCI) (CCI 1-2 OR 1.46, CCI 3-4 OR 1.59, CCI 5 OR 2.71), malnutrition (OR 2.01), physical limitations in activities of daily living (OR 2.35), and decreasing Barthel Index (BI) (OR 0.96).

CONCLUSION

After integrated orthogeriatric treatment, a significant decrease was seen in the 1-year mortality rate in the frail elderly patients with a hip fracture compared to the historical control patients who were treated with standard care. The most important risk factors for 1-year mortality were male gender, increasing age, malnutrition, physical limitations, increasing BI, and medical conditions. Awareness of risk factors that affect the 1-year mortality can be useful in optimizing care and outcomes. Orthogeriatric treatment should be standard for elderly patients with hip fractures due to the multidimensional needs of these patients.

The epidemiology of mortality after fracture in England: variation by age, sex, time, geographic location, and ethnicity

One-year mortality following a fracture was greater for men compared to women, varied markedly between regions in England with the lowest rates in the London region, and was higher among black women compared to white women. The excess in mortality did not change during the study period.

INTRODUCTION

Fractures are associated with increased mortality. With the shift towards an increasingly elderly demography, and so increasing numbers of fractures, the impact of such events on mortality is of key public health importance. Therefore, we aimed to present up-to-date mortality rates following fracture in England.

METHODS

This was a population-based study within the Clinical Practice Research Datalink, linked to death certificates (1 January 2001 to 31 December 2011). Subjects were followed from their first fracture (hip, wrist, humerus, clinical spine, ribs, or pelvis) until death for up to 1 year. Rate ratios (RRs) were estimated for 1-year mortality, stratified by sex, 5-year age categories, ethnicity, and geographical region. Excess mortality was presented as standardized mortality ratios (SMRs).

RESULTS

One-year mortality following fracture increased with age and was higher for men than women. Black women (RR 1.77; 95 % CI 1.00-3.12) and women of "other" ethnicity (RR 1.59, 95 % CI 1.16-2.16) were at higher risk of death when compared to white women. Mortality was higher among women in almost all regions when compared to the London region, with the highest risk in the East Midlands (37 % higher). The 1-year mortality risk was more than 3-fold higher after fracture as compared to the general population (adjusted SMR: 3.15, 95 % CI 3.09-3.26) and did not change during the study period. Major causes of death were neoplasms, respiratory diseases, and circulatory diseases.

CONCLUSION

This study provides up-to-date mortality outcomes following fracture in England and will aid allocation of healthcare provision to those at greatest need.