The prediction of early mortality following hip fracture surgery in patients aged 90 years and older: the Almelo Hip Fracture Score 90 (AHFS90).

The AHFS90 was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS90 has a good accuracy and in most risk categories a good calibration. In our study population, the AHFS90 yielded a maximum prediction of early mortality of 64.5%. PURPOSE: Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS90). METHODS: Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS90, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks. RESULTS: One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS90 includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS90 had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS90 overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS90 had a maximal prediction of early mortality of 64.5% in this study population. CONCLUSION: The AHFS90 accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS90 yielded a maximum prediction of early mortality of 64.5%.

Comparing three machine learning approaches to design a risk assessment tool for future fractures: predicting a subsequent major osteoporotic fracture in fracture patients with osteopenia and osteoporosis.

Four machine learning models were developed and compared to predict the risk of a future major osteoporotic fracture (MOF), defined as hip, wrist, spine and humerus fractures, in patients with a prior fracture. We developed a user-friendly tool for risk calculation of subsequent MOF in osteopenia patients, using the best performing model. INTRODUCTION: Major osteoporotic fractures (MOFs), defined as hip, wrist, spine and humerus fractures, can have serious consequences regarding morbidity and mortality. Machine learning provides new opportunities for fracture prediction and may aid in targeting preventive interventions to patients at risk of MOF. The primary objective is to develop and compare several models, capable of predicting the risk of MOF as a function of time in patients seen at the fracture and osteoporosis outpatient clinic (FO-clinic) after sustaining a fracture. METHODS: Patients aged > 50 years visiting an FO-clinic were included in this retrospective study. We compared discriminative ability (concordance index) for predicting the risk on MOF with a Cox regression, random survival forests (RSF) and an artificial neural network (ANN)-DeepSurv model. Missing data was imputed using multiple imputations by chained equations (MICE) or RSF's imputation function. Analyses were performed for the total cohort and a subset of osteopenia patients without vertebral fracture. RESULTS: A total of 7578 patients were included, 805 (11%) patients sustained a subsequent MOF. The highest concordance-index in the total dataset was 0.697 (0.664-0.730) for Cox regression; no significant difference was determined between the models. In the osteopenia subset, Cox regression outperformed RSF (p = 0.043 and p = 0.023) and ANN-DeepSurv (p = 0.043) with a c-index of 0.625 (0.562-0.689). Cox regression was used to develop a MOF risk calculator on this subset. CONCLUSION: We show that predicting the risk of MOF in patients who already sustained a fracture can be done with adequate discriminative performance. We developed a user-friendly tool for risk calculation of subsequent MOF in patients with osteopenia.

Pneumonia in hospitalized elderly hip fracture patients: the effects on length of hospital-stay, in-hospital and thirty-day mortality and a search for potential predictors.

BACKGROUND: Hip fracture in the elderly is associated with increased morbidity and mortality. Pneumonia during hospitalization is not uncommon and is associated with poorer outcomes, such as an increased risk of readmission and higher mortality rates. We aim to identify independent predictive factors for developing pneumonia during hospitalization in this group and also assessed the effect pneumonia has on hospital-stay, in-hospital and 30-day mortality. METHODS: Retrospective cohort study with prospectively collected data from hospitalized elderly hip fracture patients between January 2015 and January 2017. Examined predictors were age, gender, pre-fracture living situation, pre-fracture mobility score, pre-fracture ADL-status, history of dementia, diabetes, congestive heart failure, chronic obstructive pulmonary disease and prior stroke, ASA-score, anemia at admission, surgery within 48 hours, surgical procedure and anesthesia used. Multivariable regression analysis including resampling methods (bootstrapping) was used to examine the effects of predictors. RESULTS: Of 407 patients, 62 (15.2%) were treated for pneumonia during hospitalization. Only gender, surgery within 48 hours and history of COPD differed significantly at baseline between the groups with and without pneumonia. Adjusted for age and gender, we observed a 1.6 times longer hospital-stay (95% CI 1.4-1.9, p<0.001), higher in-hospital mortality (OR 8.0, 95% CI 2.97-22.29) and 30-day mortality (OR 3.22, 95% CI 1.44-6.94) in the pneumonia-group. Pneumonia explained 9.1% of the variance in the length of hospital-stay aside from age and gender. Eight candidate predictors from the univariate analyses with a p<0.20 were selected for a multivariable logistic regression in 1000 bootstrap samples. Gender and history of COPD were most often found to have a p<0.10 (61.3% and 58.2%, respectively) in the bootstrap analyses and more than 80% stability in their B-coefficient signs. The discriminative quality of these two variables alone resulted in an AUC of 61.7% (95% CI 54%-69%). CONCLUSION: Pneumonia resulted in longer hospital-stay and higher mortality rates. Of the 15 selected potential risk-factors for developing pneumonia during admission, male gender and history of COPD appeared to have the best potential as predictors. The other risk-factors had poorer performance, probably due to the few events and limited occurrence of some candidate variables in our study population.

'Nonagenarians' with a hip fracture: is a different orthogeriatric treatment strategy necessary?

Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group. PURPOSE: In previous literature, elderly with a hip fracture are frequently defined as ≥ 70 years. However, given the ageing population and the rapidly increasing number of 'nonagenarians' (aged ≥ 90 years), the question rises whether this definition is still actual. The aim of this study is to determine whether nonagenarians show differences compared to patients aged 70-79 years and patients aged 80-89 years in terms of patient characteristics, complications and mortality rate. METHODS: From April 2008 until December 2016, hip fracture patients aged ≥ 70 years treated according to our orthogeriatric treatment model were included. Patients were divided into three different groups based on age at admission: 70-79 years, 80-89 years and ≥ 90 years. Patient characteristics, risk of early mortality, complications and outcomes were analysed. Risk factors for 30-day mortality in nonagenarians were determined. RESULTS: A total of 1587 patients were included: 465 patients aged 70-80 years, 867 patients aged 80-90 years and 255 patients aged ≥ 90 years. Nonagenarians were more often female and had a lower haemoglobin level at admission. Prefracture, they were more often living in a nursing home, were more dependent in activities of daily living and mobility and had a higher risk of early mortality calculated with the Almelo Hip Fracture Score (AHFS). Post-operative, nonagenarians suffer significantly more often from delirium and anaemia. The 30-day mortality and 1-year mortality were significantly higher. Differences increased gradually with age. CONCLUSION: Nonagenarians differ from patients aged 70-79 and 80-89 years in baseline characteristics, complication and mortality rates. Differences increased gradually with age. The results of this study can be used, in combination with the Almelo Hip Fracture Score, to deliver efficiently targeted orthogeriatric treatment to the right patient group.

The consistency of care for older patients with a hip fracture: are the results of the integrated orthogeriatric treatment model of the Centre of Geriatric Traumatology consistent 10 years after implementation?

In the past 10 years after implementation, the orthogeriatric treatment model led in general to consistent outcomes for 1555 older adults in terms of most of the complications and mortality. Surgery was more often delayed to 24-48 h after arrival at the hospital, while the length of hospital stay shortened. INTRODUCTION: Since 1 April 2008, patients aged ≥ 70 years presenting themselves with a hip fracture at Ziekenhuisgroep Twente (ZGT) have been treated according to the orthogeriatric treatment model. The aim of this study was to investigate if outcomes of the orthogeriatric treatment model are consistent over the first 10 years after implementation. METHODS: Between 1 April 2008 and 31 December 2016, patients aged ≥ 70 years who were surgically treated at ZGT for a hip fracture were included and divided into three periods equally distributed in time. Patient characteristics, in-hospital logistics, complications, and mortality data were compared between the three periods. RESULTS: A total of 1555 patients were included. There was a shift in the surgical treatment for the fractured neck of femur from dynamic hip screw/cannulated screws to hemiarthroplasty (p < 0.001). Surgery within 24 h after arrival to the hospital decreased (p < 0.001), while surgery within 48 h stayed the same (p = 0.085). Length of hospital stay significantly decreased over time (p < 0.001). Complication rates were consistent except for the number of postoperative anemia, delirium, and urinary tract infections. Mortality rates did not change over the years. CONCLUSIONS: The orthogeriatric treatment model leads in general to consistent outcomes concerning mortality and most of the complications, except for postoperative anemia, delirium, and urinary tract infections. Inconsistent complication rates were influenced by altered diagnosis and treatment protocols. Length of hospital stay reduced, while time to surgery was more often delayed to 24-48 h. Monitoring clinical outcomes of the orthogeriatric treatment model over time is recommended in order to optimize and maintain the quality of care for this frail patient population.

Prediction of early mortality following hip fracture surgery in frail elderly: The Almelo Hip Fracture Score (AHFS).

BACKGROUND: Hip fractures are common in the elderly and have a high risk of early mortality. Identification of patients at high risk of early mortality could contribute to enhanced quality of care. A simple scoring system is essential for preoperative identification of patients at high risk of early mortality in clinical practice. Of risk models published, The Nottingham Hip Fracture Score (NHFS) shows the most promising results so far. However, there is still room for improvement. METHODS: A cohort study including 850 patients was conducted over a period of 5,5 yr. The NHFS was adjusted for cognitive impairment (NHFS-a) and tested. Patients who died within 30days following hip fracture surgery (early mortality group) were compared to survivors. Independent risk factors for early mortality were assessed. A new hip fracture score for frail elderly was developed: the Almelo Hip Fracture Score (AHFS). The NHFS-a and the AHFS were compared for accuracy and predictive validity. RESULTS: Sixty-four (7.5%) patients died within 30days following hip fracture surgery. The AHFS predicts the risk of early mortality better than the NHFS-a (p<0.05). Using cut-off points of AHFS ≤ 9 and AHFS ≥ 13, patients could be divided into a low, medium or high risk group. The area under the curve improved with the AHFS compared to the NHFS-a (0.82 versus 0.72). The likelihood ratio test reveals a significantly better fit of the AHFS in comparison with the NHFS-a (p<0.001). CONCLUSIONS: The AHFS can identify frail elderly at high risk of early mortality following hip fracture surgery accurately. With the AHFS, the patient can be classified into the low, medium or high risk group, which contributes to enhanced quality of care in clinical practice.