Predictors of mortality over time in geriatric patients with hip fracture.

Objectives: The aim of this study was to determine the variations in effect for predictors of mortality over time and risk of in-hospital complications in geriatric patients with a hip fracture. Many studies have investigated risk factors of short-term and long-term mortality separately. In current literature, little is known about the variations in effect of risk factors over time and no comparison with the general population is made. Methods: All patients with a hip fracture aged 70 years or older admitted to our hospital between January 1, 2016, and May 1, 2018, were included in this retrospective study. Patients who had undergone total hip arthroplasty (THA) were not included. The primary outcome was mortality after 1 year. Secondary outcomes were mortality after 30 days, 90 days, 2 years, and complications. Kaplan-Meier (KM) curves for risk factors were generated to visualize survival over time. Data were compared with data extracted from the national health records. Results: A total of 685 geriatric patients with hip fractures were included with a 1-year mortality of 27%. The adjusted odds ratios (AOR) found differed over time. Five risk factors for mortality were investigated in this study using KM curves: age, prefracture living situation, dementia, sex, and ASA classification. Conclusions: Over time, the variation of 5 risk factors for mortality were visualized in geriatric patients with a hip fracture: age, prefracture living situation, dementia, sex, and ASA classification. An elevated risk of mortality was discovered compared with the general population. The variation in effect observed in risk factors plays a vital role in prognosis. This insight will help guide accurate medical decision-making for a tailored treatment plan for geriatric patients with a hip fracture.

Inter-rater agreement in pPOSSUM scores of geriatric trauma patients: a prospective evaluation.

PURPOSE: Risk prediction models are widely used in the perioperative setting to identify high-risk patients who may benefit from additional care and to aid clinical decision-making. pPOSSUM is such a prediction model, however, little is known about the inter-rater agreement when scoring subjective parameters. This study assessed the inter-rater agreement between clinicians of different specialties and work-level when scoring 30 clinical case reports of geriatric hip fracture patients with pPOSSUM. METHODS: Eighteen clinicians of the department of Surgery (three specialists, four residents), Anaesthesiology (four specialists, two residents) and Emergency Medicine (three specialists, two residents) who were familiar with the pPOSSUM scoring system were asked to calculate the scores. The kappa statistic and the statistical method of Fleiss were used to analyse inter-rater agreement. RESULTS: The response rate was 100%. Among surgeons, Anaesthesiologists and Emergency department doctors (ED), the overall mean kappa values were 0.42, 0.08 and 0.20, respectively. Among surgery, anaesthesiology and ED residents the overall mean kappa values were 0.21, 0.33 and 0.37, respectively. Within the department of Surgery, Anaesthesiology and Emergency Medicine the overall mean kappa values were 0.23, 0.12 and 0.22, respectively. An overall mean kappa value of 0.19 was seen among all specialists. All residents had an overall mean kappa value of 0.21 and all clinicians had an overall mean kappa value of 0.21. CONCLUSION: The overall inter-rater agreement of clinicians and interdisciplinary agreement when scoring geriatric hip fracture patients with pPOSSUM was low and prone to subjectivity in our study. A higher work-experience level did not lead to better agreement. When pPOSSUM is calculated without clinical assessment by the same clinician, caution is advised to prevent over-reliance on the pPOSSUM risk prediction model. LEVEL OF EVIDENCE: III.

Is the Parker Mobility Score in the older patient with a traumatic hip fracture associated with discharge disposition after surgery? A retrospective cohort study.

PURPOSE: The research questions for this study were as follows: (1) is the Parker Mobility Score (PMS) associated with discharge disposition and hospital length of stay (HLOS) of geriatric traumatic hip fracture patients? (2) Can the PMS be incorporated in a decision tree for the prediction of discharge disposition of geriatric traumatic hip fracture patients upon admittance. METHODS: A dual-center retrospective cohort study was conducted at two level II trauma centers. All patients aged 70 years and older with traumatic hip fractures undergoing surgery in 2018 and 2019 were included consecutively (n = 649). A χ2 automatic interaction detection analysis was performed to determine the association of the PMS (and other variables) with discharge disposition and HLOS and predict discharge destination. RESULTS: The decision tree for discharge disposition classified patients with an overall accuracy of 82.1% and a positive predictive value of 91% for discharge to a rehabilitation facility. The PMS had the second most significant effect on discharge disposition (χ2 = 22.409, p < 0.001) after age (χ2 = 79.094, p < 0.001). Regarding the tree analysis of HLOS, of all variables in the analysis, PMS had the most significant association with HLOS (F = 14.891, p < 0.001). Patients who were discharged home had a mean HLOS of 6.5 days (SD 8.0), whereas patients who were discharged to an institutional care facility had a mean HLOS of 9.7 days (SD 6.4; p < 0.001). CONCLUSION: This study shows that the PMS was strongly associated with discharge disposition and HLOS. The decision tree for the discharge disposition of geriatric traumatic hip fracture patients offers a practical solution to start discharge planning upon admittance which could potentially reduce HLOS. LEVEL OF EVIDENCE: Level III, diagnostic.

Efficacy of two integrated geriatric care pathways for the treatment of hip fractures: a cross-cultural comparison.

INTRODUCTION: Many studies have focussed on the implementation and outcomes of geriatric care pathways (GCPs); however, little is known about the possible impact of clinical practices on these pathways. A comparison was made between two traumageriatric care models, one Swiss (CH) and one Dutch (NL), to assess whether these models would perform similarly despite the possible differences in local clinical practices. MATERIALS AND METHODS: This cohort study included all patients aged 70 years or older with a unilateral hip fracture who underwent surgery in 2014 and 2015. The primary outcomes were mortality and complications. Secondary outcomes were time to surgical intervention, hospital length of stay (HLOS), differences in surgical treatment and the number of patients who needed secondary surgical intervention. RESULTS: A total of 752 patients were included. No differences were seen in mortality at 30 days, 90 days and 1 year post-operatively. In CH, fewer patients had a complicated course (43.5% vs. 51.3%; p = 0.048) and fewer patients were diagnosed with delirium (7.9% vs. 18.3%; p < 0.01). More myocardial infarctions (3.8% vs. 0.4%; p < 0.01) and red blood cell transfusions (27.2% vs. 13.3%; p < 0.01) were observed in CH and HLOS in CH was longer (Mdn difference: - 2; 95% CI - 3 to - 2). Furthermore, a difference in anaesthetic technique was found, CH performed more open reductions and augmentations than NL and surgeons in CH operated more often during out-of-office hours. Also, surgery time was significantly longer in CH (Mdn difference: - 62; 95% CI - 67 to - 58). No differences were seen in the number of patients who needed secondary surgical interventions. CONCLUSIONS: This cross-cultural comparison of GCPs for geriatric hip fracture patients showed that quality of care in terms of mortality was equal. The difference in complicated course was mainly caused by a difference in delirium diagnosis. Differences were seen in surgical techniques, operation duration and timing. These clinical practices did not influence the outcome.

The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study.

PURPOSE: Hip fractures are a common health problem among the elderly with an increasing incidence. They are associated with high mortality and morbidity. Optimal pain management remains challenging and inadequate pain control is known for negatively affecting outcomes. Loco-regional anaesthetics (LRA) have been proven to benefit pain management and to lower the risks of opioid use and -related side effects. We aimed to evaluate the use and efficacy of different LRA in elderly hip fracture patients. METHODS: Single-center cohort study of elderly hip fracture patients, who were treated in central Switzerland. We compared patients who received LRA in the form of a femoral nerve block (FNB) or a continuous femoral nerve catheter (CFNC) with patients who did not receive LRA. Primary outcomes were pain-as measured in perioperative morphine use-hospital length of stay (HLOS), postoperative complications, postoperative falls and mortality. RESULTS: 407 patients were included for analysis. Mean age was 85.2 (SD6.3). There was a significant difference in intraoperative morphine use between the groups (p = 0.007). Postoperative morphine use differed significantly and was lowest in patients with FNB and highest in patients without LRA (p < 0.001). The use of LRA was a significant predictor for postoperative morphine use for postoperative morphine use at the recovery room and for postoperative morphine use 48 h after surgery. No significant differences were found in postoperative complications, a significant difference was found in 1-year mortality. CONCLUSIONS: This article shows that LRA in the form of FNB and CFNC causes a significant decrease in postoperative opioid consumption. Differences between single-shot FNB or CFNC were minimal. There were no significant differences in clinical outcomes such as HLOS, delirium, 30-day and 90-day mortality and postoperative falls. We suggest that use of LRA should be incorporated in the perioperative treatment of elderly patients with a hip fracture. For future research, we recommend evaluating the number of postoperative complications and mortality.

The Quality of Life, Patient Satisfaction and Rehabilitation in Patients With a Low Energy Fracture-Part III of an Observational Study.

INTRODUCTION: Due to the aging population the incidence of Low Energy Fractures (LEF) increases. LEF have high mortality and morbidity rates and often cause elderly to lose independence. Patient-reported outcomes, such as Quality of Life (QoL) and patient satisfaction (PS) are needed to evaluate treatment, estimate cost-benefit analyses, and to improve clinical decision-making and patient-centered care. OBJECTIVE: The primary goal was to evaluate QoL and PS in patients with LEF, and to compare QoL scores to the community dwelling population. Second, we observed the amount and type of physiotherapy (PT) sessions the patients conducted. METHODS: A single-center cohort study was conducted in Switzerland. Patients between 50 and 85 years, who were treated in the hospital for LEF, were followed 1 year after initial fracture. Data on QoL were obtained through the Euroqol-5-Dimension questionnaire-3-Level (EQ-5D-3L) and the EQ VAS (visual analog scale). PS was measured by a VAS on satisfaction with treatment outcome. Data on PT sessions, mobility and use of analgesics were collected by telephone interviews and written surveys. Results were compared between the different fracture locations and subgroup analyses were performed for age categories. RESULTS: 411 patients were included for analysis. The median scores of the EQ-5D-3L index-VAS and PS were 0.90 (0.75-1.0), 90 (71.3-95) and 100 (90-100). Significant differences in all scores were found between fracture location (P < .05), with hip fracture patients and patients with a malleolar fracture scoring lowest in all measures. QoL index in hip fracture patients was 0.76 (0.70-1.00), QoL VAS 80 (70-90), and PS 95 (80-100). Median amount of PT sessions in all patients was 18 (9-27) and a significant difference was found between fracture locations. Patients with a fracture of the humerus received the highest amount of PT sessions 27 (18-36), hip fracture patients had a median of 18 (9-27) sessions. CONCLUSION: At follow-up, QoL throughout all patients with a LEF was comparable to a normal population. Remarkably, though hip fracture patients seem to suffer from a clinically relevant loss of QoL, they received fewer PT sessions and performed fewer long-lasting home training than patients with a humerus fracture. Intensive, progressive rehabilitation with a high frequency of supervised training is recommended after hip fracture. The low frequency of PT sessions found in this study is unsatisfying. In hip fracture patients and in patients with a malleolar fracture, especially when aged over 75 years, more efforts are required to improve rehabilitation and subsequently QoL.

Fear of Falling, Recurrence of Falls, and Quality of Life in Patients with a Low Energy Fracture-Part II of an Observational Study.

Background and objective: Falls in elderly cause injury, mortality, and loss of independence, making Fear of Falling (FoF) a common health problem. FoF relates to activity restriction and increased fall risk. A voluntary intervention including fall risk assessment and prevention strategies was implemented to reduce falls in elderly patients with low energy fractures (LEF). The primary purpose of this study was to evaluate FoF and the number of subsequent falls in trauma patients one year after a LEF. The secondary aim was to examine how FoF affects patients' lives in terms of Quality of Life (QoL), mobility, and activity levels. Finally, participation in the voluntary fall prevention program (FPP) was evaluated. Materials and Methods: Observational cohort study in one Swiss trauma center. LEF patients, treated between 2012 and 2015, were analyzed one year after injury. Primary outcomes were Falls-Efficacy Score-International (FES-I) and number of subsequent falls. Secondary outcomes were EuroQoL-5-Dimensions-3-Levels (EQ5D-3L), mobility, activity levels, and participation in the FPP. Subgroup analysis was performed for different age categories. Results: 411 patients were included for analysis. Mean age was 72 ± 9.3, mean FES-I was 21.1 ± 7.7. Forty percent experienced FoF. A significant negative correlation between FoF and QoL (R = 0.64; p < 0.001) was found. High FoF correlated with lower activity levels (R= -0.288; p < 0.001). Six percent visited the FPP. Conclusions: At follow-up, 40% suffered from FoF which seems to negatively affect patients' QoL. Nevertheless, participation in the FPP was low. Simply informing patients about their susceptibility to falls and recommending participation in FPPs seems insufficient to motivate and recruit patients into FPPs. We suggest implementing repeated fall risk- and FoF screenings as standard procedures in the follow-up of LEF, especially in patients aged over 75 years.

Different approaches towards geriatric trauma care for hip fracture patients: an inter-hospital comparison.

PURPOSE: Hip fractures in geriatric patients have high morbidity and mortality rates. The implementation of a multidisciplinary geriatric care pathway (GCP) may improve treatment for this patient population. This study focusses on two level II hospitals with a different treatment protocols. A comparison was made between a multidisciplinary GCP and extensive standard care with a focus on geriatric hip fracture patients to assess if a multidisciplinary GCP leads to lower mortality and morbidity. METHODS: This retrospective cohort study included patients aged 70 years or older with a unilateral proximal hip fracture who underwent surgery between January 2014 and December 2015. The primary outcome measures complications and 30-day mortality. Secondary outcome measures were time to surgery, hospital length of stay (HLOS) and secondary surgical interventions. RESULTS: This study included a total of 898 patients. No differences were found between major postoperative complications, 30-day mortality, HLOS or the amount of secondary surgical interventions. CONCLUSIONS: Mortality, major complications, HLOS and the amount of secondary surgical interventions showed no differences between both hospitals. This inter-hospital comparison of two types of geriatric care models showed no outcome that favours one specific geriatric care model over another. This provides opportunities for future studies to get a better understanding of what specific factors of geriatric care models contribute most to an improvement in the treatment of this patient population and decide which approach is most cost effective.

Orthogeriatric Trauma Unit Improves Patient Outcomes in Geriatric Hip Fracture Patients.

INTRODUCTION: An aging population in developed countries has increased the number of osteoporotic hip fractures and will continue to grow over the next decades. Previous studies have investigated the effect of integrated orthogeriatric trauma units and care model on outcomes of hip fracture patients. Although all of the models perform better than usual care, there is no conclusive evidence which care model is superior. More confirmative studies reporting the efficacy of orthogeriatric trauma units are needed. The objective of this study was to evaluate outcomes of hip fracture patients admitted to the hospital before and after implementation of an orthogeriatric trauma unit. MATERIALS AND METHODS: This retrospective cohort study was conducted at a level 2 trauma center between 2016 and 2018. Patients aged 70 years or older with a hip fracture undergoing surgery were included to evaluate the implementation of an orthogeriatric trauma unit. The main outcomes were postoperative complications, patient mortality, time spent at the emergency department, time to surgery, and hospital length of stay. RESULTS: A total of 806 patients were included. After implementation of the orthogeriatric trauma unit, there was a significant decrease in postoperative complications (42% vs. 49% in the historical cohort, p = 0.034), and turnaround time at the emergency department was reduced by 38 minutes. Additionally, there was significantly less missing data after implementation of the orthogeriatric trauma unit. After correcting for covariates, patients in the orthogeriatric trauma unit cohort had a lower chance of complications (OR 0.654, 95% CI 0.471-0.908, p = 0.011) and a lower chance of 1-year mortality (OR 0.656, 95% CI 0.450-0.957, p = 0.029). CONCLUSIONS: This study showed that implementation of an orthogeriatric trauma unit leads to a decrease in postoperative complications, 1-year mortality, and time spent at the emergency department, while also improving the quality of data registration for clinical studies. LEVEL OF EVIDENCE: Level III.