The impact of cognitive function on physical activity, physical function and quality of life in older adults following a hip fracture.

OBJECTIVE: To determine the impact of cognitive function on physical activity (PA), physical function and health-related quality of life (HRQoL) in older adults within the first year after hip fracture (HF) surgery. METHODS: We included 397 home-dwelling individuals aged 70 years or older with the ability to walk 10 m before the fracture. Cognitive function was measured at 1 month and other outcomes were assessed at 1, 4 and 12 months postoperatively. Mini-Mental State Examination was used to assess cognitive function, accelerometer-based body-worn sensors to register PA, Short Physical Performance Battery to test physical function and EuroQol-5-dimension-3-level to estimate the HRQoL. Data were analysed by linear mixed-effects models with interactions and ordinal logistic regression models. RESULTS: Cognitive function, adjusted for the pre-fracture ability to perform activities of daily living, comorbidity, age and gender, had an impact on PA [b = 3.64, 95% confidence interval (CI): 2.20-5.23, P < 0.001] and physical function (b = 0.08, 95% CI: 0.04-0.11, P < 0.001; b = 0.12, 95% CI: 0.09-0.15, P < 0.001; and b = 0.14, 95% CI: 0.10-0.18, P < 0.001 at 1, 4 and 12 months, respectively). The cognitive function did not have a considerable impact on HRQoL. CONCLUSIONS: For older adults with HFs, cognitive function 1 month postoperatively had a significant impact on PA and physical function in the first postoperative year. For the HRQoL, little or no evidence of such an effect was found.

Health care services and costs after hip fracture, comparing conventional versus standardised care: A retrospective study with 12-month follow-up.

AIMS: To compare costs related to a standardised versus conventional hospital care for older patients after fragility hip fracture and determine whether a shift in hospital care led to cost-shifts between specialists and primary health care. METHODS: We retrospectively collected and calculated volumes of care and accompanying costs from fracture time until 12 months after hospital discharge for 979 patients. All patients aged ≥ 65 years had fragility hip fractures. The data set had few missing data points because of the patient registry, administrative databases, and a low migration rate. RESULTS: Total costs per patient at 12 months were EUR 78 164 (standard deviation [SD] 58 056) and EUR 78 068 (SD 60 131) for conventional and standardised care, respectively (p = 0.480). Total specialist care costs were significantly lower for the standardised care group (p < 0.001). Total primary care costs were higher for the standardised care group (p = 0.424). Total costs per day of life for the conventional and standardised care groups were EUR 434 and EUR 371, respectively (p = 0.003). Patients in the standardised care group had 17 more days of life. CONCLUSIONS: Implementation of a standardised care to improve outcomes for patients with hip fracture caused lower specialist care costs and higher primary care costs, indicating care- and cost-shifts from specialist to primary health care.

A prospective randomized trial of 100 patients using trochanteric support plates; worth their mettle?

BACKGROUND AND PURPOSE: To compare the radiological and clinical results of sliding hip screw (SHS) fixation with or without a Trochanteric Support Plate (TSP) on unstable three-or-more-part trochanteric fractures. METHODS: A randomized prospective non blinded study of one hundred patients with trochanteric fractures; Evans-Jensen type 3, 4 and 5, reduced and fixed with SHS. Patients were randomized into two study groups; with or without TSP supplementation ('TSP' and 'NoTSP' groups). Radiologic measurements of the hip in the frontal plane (primary outcome), including fracture movement, nonunion and loss of fixation were measured, as well as pain, ambulation, mobility, institution residence, complications and death, twelve months post operatively (secondary outcomes). RESULTS: At one-year follow-up four patients in the TSP and ten patients in the NoTSP group had either died or been lost in follow-up. Within this period, forty-three fractures healed and three had a loss of fixation in the TSP group; thirty-nine fractures healed and one had a loss of fixation in the NoTSP group. Frontal X-rays showed fracture subsidence on average 1 mm less in the TSP group compared to the NoTSP group. This difference was negligible, as was the difference in all subgroups, in fixation failure/cutout, modified Merle d'Aubigne Postel scores (measuring function and pain), institution residence, complications and death between the groups. INTERPRETATION: This study cannot confirm that TSP has any beneficial effects on unstable three-or-more-part trochanteric fractures. If any effect at all, the difference is most likely slight and clinically irrelevant.

Mortality and readmission following hip fracture surgery: a retrospective study comparing conventional and fast-track care.

OBJECTIVE: To compare the efficacies of two pathways-conventional and fast-track care-in patients with hip fracture. DESIGN: Retrospective single-centre study. SETTING: University hospital in middle Norway. PARTICIPANTS: 1820 patients aged ≥65 years with hip fracture (intracapsular, intertrochanteric or subtrochanteric). INTERVENTIONS: 788 patients were treated according to conventional care from April 2008 to September 2011, and 1032 patients were treated according to fast-track care from October 2011 to December 2013. PRIMARY AND SECONDARY OUTCOME: Primary: mortality and readmission to hospital, within 365 days follow-up. Secondary: length of stay. RESULTS: We found no statistically significant differences in mortality and readmission rate between patients in the fast-track and conventional care models within 365 days after the initial hospital admission. The conventional care group had a higher, no statistical significant mortality HR of 1.10 (95% CI 0.91 to 1.31, p=0.326) without and 1.16 (95% CI 0.96 to 1.40, p=0.118) with covariate adjustment. Regarding the readmission, the conventional care group sub-HR was 1.02 (95% CI 0.88 to 1.18, p=0.822) without and 0.97 (95% CI 0.83 to 1.12, p=0.644) with adjusting for covariates. Length of stay and time to surgery was statistically significant shorter for patients who received fast-track care, a mean difference of 3.4 days and 6 hours, respectively. There was no statistically significant difference in sex, type of fracture, age or Charlson Comorbidity Index score at baseline between patients in the two pathways. CONCLUSIONS: There was insufficient evidence to show an impact of fast-track care on mortality and readmission. Length of stay and time to surgery were decreased. TRIAL REGISTRATION NUMBER: NCT00667914; results.

Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial.

BACKGROUND: Most patients with hip fractures are characterised by older age (>70 years), frailty, and functional deterioration, and their long-term outcomes are poor with increased costs. We compared the effectiveness and cost-effectiveness of giving these patients comprehensive geriatric care in a dedicated geriatric ward versus the usual orthopaedic care. METHODS: We did a prospective, single-centre, randomised, parallel-group, controlled trial. Between April 18, 2008, and Dec 30, 2010, we randomly assigned home-dwelling patients with hip-fractures aged 70 years or older who were able to walk 10 m before their fracture, to either comprehensive geriatric care or orthopaedic care in the emergency department, to achieve the required sample of 400 patients. Randomisation was achieved via a web-based, computer-generated, block method with unknown block sizes. The primary outcome, analysed by intention to treat, was mobility measured with the Short Physical Performance Battery (SPPB) 4 months after surgery for the fracture. The type of treatment was not concealed from the patients or staff delivering the care, and assessors were only partly masked to the treatment during follow-up. This trial is registered with ClinicalTrials.gov, number NCT00667914. FINDINGS: We assessed 1077 patients for eligibility, and excluded 680, mainly for not meeting the inclusion criteria such as living in a nursing home or being aged less than 70 years. Of the remaining patients, we randomly assigned 198 to comprehensive geriatric care and 199 to orthopaedic care. At 4 months, 174 patients remained in the comprehensive geriatric care group and 170 in the orthopaedic care group; the main reason for dropout was death. Mean SPPB scores at 4 months were 5·12 (SE 0·20) for comprehensive geriatric care and 4·38 (SE 0·20) for orthopaedic care (between-group difference 0·74, 95% CI 0·18-1·30, p=0·010). INTERPRETATION: Immediate admission of patients aged 70 years or more with a hip fracture to comprehensive geriatric care in a dedicated ward improved mobility at 4 months, compared with the usual orthopaedic care. The results suggest that the treatment of older patients with hip fractures should be organised as orthogeriatric care. FUNDING: Norwegian Research Council, Central Norway Regional Health Authority, St Olav Hospital Trust and Fund for Research and Innovation, Liaison Committee between Central Norway Regional Health Authority and the Norwegian University of Science and Technology, the Department of Neuroscience at the Norwegian University of Science and Technology, Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF), and the Municipality of Trondheim.

Long-term outcome and quality of life after craniectomy in speech-dominant swollen middle cerebral artery infarction.

BACKGROUND: Decompressive craniectomy in malignant middle cerebral artery infarction (MMCAI) reduces mortality. Whether speech-dominant side infarction results in less favorable outcome is unclear. This study compared functional outcome, quality of life, and mental health among patients with speech-dominant and non-dominant side infarction. METHODS: All patients undergoing decompressive craniectomy for MMCAI were included. Demographics, side of infarction, and speech-dominant hemisphere were recorded. Outcome at follow-up was assessed by global functioning (modified Rankin Scale score), neurological impairment (National Institutes of Health Stroke Scale score), dependency (Barthel Index), anxiety and depression (Hospital Anxiety and Depression scale), and quality of life (Short Form-36). RESULTS: Twenty-nine out of 45 patients (mean age ± SD, 48.1 ± 11.6 years; 58 % male) were alive at follow-up, and 26 were eligible for analysis [follow-up, median (interquartile range): 66 months (32-93)]. The speech-dominant hemisphere was affected in 13 patients. Outcome for patients with speech-dominant and non-dominant side MMCAI was similar regarding neurological impairment (National Institutes of Health Stroke Scale score, mean ± SD: 10.3 ± 7.0 vs. 8.9 ± 2.7, respectively; p = 0.51), global functioning [modified Rankin Scale score, median (IQR): 3.0 [2-4] vs. 4.0 [3-4]; p = 0.34], dependence (Barthel Index, mean ± SD: 16.2 ± 5.0 vs. 13.1 ± 4.8; p = 0.12), and anxiety and depression (Hospital Anxiety and Depression scale, mean ± SD: anxiety, 5.0 ± 4.5 vs. 7.3 ± 5.8; p = 0.30; depression, 5.0 ± 5.2 vs. 5.9 ± 3.9; p = 0.62). The mean quality of life scores (Short Form-36) were not significantly different between the groups. CONCLUSIONS: There was no statistical or clinical difference in functional outcome and quality of life in patients with speech-dominant compared to non-dominant side infarction. The side affected should not influence suitability for decompressive craniectomy.

Comparison of the SF6D, the EQ5D, and the oswestry disability index in patients with chronic low back pain and degenerative disc disease.

BACKGROUND: The need for cost effectiveness analyses in randomized controlled trials that compare treatment options is increasing. The selection of the optimal utility measure is important, and a central question is whether the two most commonly used indexes - the EuroQuol 5D (EQ5D) and the Short Form 6D (SF6D) - can be used interchangeably. The aim of the present study was to compare change scores of the EQ5D and SF6D utility indexes in terms of some important measurement properties. The psychometric properties of the two utility indexes were compared to a disease-specific instrument, the Oswestry Disability Index (ODI), in the setting of a randomized controlled trial for degenerative disc disease. METHODS: In a randomized controlled multicentre trial, 172 patients who had experienced low back pain for an average of 6 years were randomized to either treatment with an intensive back rehabilitation program or surgery to insert disc prostheses. Patients filled out the ODI, EQ5D, and SF-36 at baseline and two-year follow up. The utility indexes was compared with respect to measurement error, structural validity, criterion validity, responsiveness, and interpretability according to the COSMIN taxonomy. RESULTS: At follow up, 113 patients had change score values for all three instruments. The SF6D had better similarity with the disease-specific instrument (ODI) regarding sensitivity, specificity, and responsiveness. Measurement error was lower for the SF6D (0.056) compared to the EQ5D (0.155). The minimal important change score value was 0.031 for SF6D and 0.173 for EQ5D. The minimal detectable change score value at a 95% confidence level were 0.157 for SF6D and 0.429 for EQ5D, and the difference in mean change score values (SD) between them was 0.23 (0.29) and so exceeded the clinical significant change score value for both instruments. Analysis of psychometric properties indicated that the indexes are unidimensional when considered separately, but that they do not exactly measure the same underlying construct. CONCLUSIONS: This study indicates that the difference in important measurement properties between EQ5D and SF6D is too large to consider them interchangeable. Since the similarity with the "gold standard" (the disease-specific instrument) was quite different, this could indicate that the choice of index should be determined by the diagnosis.

Reliability of change in lumbar MRI findings over time in patients with and without disc prosthesis--comparing two different image evaluation methods.

OBJECTIVES: To assess the reliability of change in lumbar magnetic resonance imaging (MRI) findings evaluated retrospectively by direct comparison of images and by non-comparison. MATERIALS AND METHODS: Pre-treatment and 2-year follow-up MRI was performed in 126 patients randomized to disc prosthesis surgery or non-surgical treatment. Two experienced radiologists independently evaluated progress and regress for Modic changes, disc findings, and facet arthropathy (FA) at L3/L4, L4/L5, and L5/S1, both by non-comparison and by comparison of initial and follow-up images. FA was evaluated at all levels, and other findings at non-operated levels. We calculated prevalence- and bias-adjusted kappa (PABAK) values for interobserver agreement. The impact of an adjacent prosthesis (which causes artefacts) and image evaluation method on PABAK was assessed using generalized estimating equations. RESULTS: Image comparison indicated good interobserver agreement on progress and regress (PABAK 0.63-1.00) for Modic changes, posterior high-intensity zone, disc height, and disc contour at L3-S1 and for nucleus pulposus signal and FA at L3/L4; and moderate interobserver agreement (PABAK 0.46-0.59) on decreasing nucleus signal and increasing FA at L4-S1. Image comparison indicated lower (but fair) interobserver agreement (PABAK 0.29) only for increasing FA at L5/S1 in patients with prosthesis in L4/L5 and/or L5/S1. An adjacent prosthesis had no overall impact on PABAK values (p ≥ 0.22). Comparison yielded higher PABAK values than non-comparison (p < 0.001). CONCLUSIONS: Regarding changes in lumbar MRI findings over time, comparison of images can provide moderate or good interobserver agreement, and better agreement than non-comparison. An adjacent prosthesis may not reduce agreement on change for most findings.

Reliability of MRI findings in candidates for lumbar disc prosthesis.

INTRODUCTION: Limited reliability data exist for localised magnetic resonance imaging (MRI) findings relevant to planning of treatment with lumbar disc prosthesis and later outcomes. We assessed the reliability of such findings in chronic low back pain patients who were accepted candidates for disc prosthesis. METHODS: On pretreatment MRI of 170 patients (mean age 41 years; 88 women), three experienced radiologists independently rated Modic changes, disc findings and facet arthropathy at L3/L4, L4/L5 and L5/S1. Two radiologists rerated 126 examinations. For each MRI finding at each disc level, agreement was analysed using the kappa statistic and differences in prevalence across observers using a fixed effects model. RESULTS: All findings at L3/L4 and facet arthropathy at L5/S1 had a mean prevalence <10% across observers and were not further analysed, ensuring interpretable kappa values. Overall interobserver agreement was generally moderate or good (kappa 0.40-0.77) at L4-S1 for Modic changes, nucleus pulposus signal, disc height (subjective and measured), posterior high-intensity zone (HIZ) and disc contour, and fair (kappa 0.24) at L4/L5 for facet arthropathy. Posterior HIZ at L5/S1 and severely reduced subjective disc height at L4/L5 differed up to threefold in prevalence between observers (p < 0.0001). Intraobserver agreement was mostly good or very good (kappa 0.60-1.00). CONCLUSION: In candidates for disc prosthesis, mostly moderate interobserver agreement is expected for localised MRI findings.

Hip fracture incidence in central norway: a followup study.

Studies in the 1980s, including one from central Norway, in most cases showed that the incidence of hip fractures was increasing. In the 1990s, however, studies from Sweden and the United States indicated that the increase may have stopped. We report the current incidence of hip fractures in subjects in central Norway and compare it with that previously reported. The number of cervical and trochanteric fractures in a defined region of Central Norway in 1992 to 1993 and in 1997 to 1998 was found by a thorough search and collation of the hand written surgery reports, the reports from radiology departments, and hospital discharge reports. One thousand three hundred twelve hip fractures were sustained during 1997 to 1998, 10% more than in the preceding period. This was almost entirely attributable to aging of the population. In contrast to the highly statistically significant increase in the actual incidence of 2% per year previously reported between 1972 to 1973 and 1983 to 1984, there was no statistically significant increase in incidence between 1983 to 1984 and 1997 to 1998 (0.55% per year). The incidence of hip fractures was 18% higher in subjects in urban areas than in subjects in rural areas in 1992 to 1993, and 33% higher in 1997 to 1998. Whereas the proportion of trochanteric fractures was 32% in 1972 to 1973 and in 1983 to 1984, it increased to 44% in 1992 to 1993 and to 68% in 1997 to 1998. There has been an insignificant increase in hip fracture incidence since 1983 to 1984. The lower incidence of hip fractures in subjects in rural areas persists, and there has been a dramatic increase in the proportion of trochanteric fractures.