IMPORTANCE: Little is known regarding outcomes after hip fracture among long-term nursing home residents. OBJECTIVE: To describe patterns and predictors of mortality and functional decline in ...activities of daily living (ADLs) among nursing home residents after hip fracture. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 60 111 Medicare beneficiaries residing in nursing homes who were hospitalized with hip fractures between July 1, 2005, and June 30, 2009. MAIN OUTCOMES AND MEASURES: Data sources included Medicare claims and the Nursing Home Minimum Data Set. Main outcomes included death from any cause at 180 days after fracture and a composite outcome of death or new total dependence in locomotion at the latest available assessment within 180 days. Additional analyses described within-residents changes in function in 7 ADLs before and after fracture. RESULTS: Of 60 111 patients, 21 766 (36.2%) died by 180 days after fracture; among patients not totally dependent in locomotion at baseline, 53.5% died or developed new total dependence within 180 days. Within individual patients, function declined substantially after fracture across all ADL domains assessed. In adjusted analyses, the greatest decreases in survival after fracture occurred with age older than 90 years (vs ≤75 years: hazard ratio HR, 2.17; 95% CI, 2.09-2.26 P < .001), nonoperative fracture management (vs internal fixation: HR for death, 2.08; 95% CI, 2.01-2.15 P < .001), and advanced comorbidity (Charlson score of ≥5 vs 0: HR, 1.66; 95% CI, 1.58-1.73 P < .001). The combined risk of death or new total dependence in locomotion within 180 days was greatest among patients with very severe cognitive impairment (vs intact cognition: relative risk RR, 1.66; 95% CI, 1.56-1.77 P < .001), patients receiving nonoperative management (vs internal fixation: RR, 1.48; 95% CI, 1.45-1.51 P < .001), and patients older than 90 years (vs ≤75 years: RR, 1.42; 95% CI, 1.37-1.46 P < .001). CONCLUSIONS AND RELEVANCE: Survival and functional outcomes are poor after hip fracture among nursing home residents, particularly for patients receiving nonoperative management, the oldest old, and patients with multiple comorbidities and advanced cognitive impairment. Care planning should incorporate appropriate prognostic information related to outcomes in this population.
Mortality is increased in the year after a hip fracture, and strategies that improve the outcome are needed. This randomized, double-blind, placebo-controlled trial compared yearly intravenous ...zoledronic acid with placebo first administered within 90 days after surgical repair of a hip fracture in patients who were unable or unwilling to take oral bisphosphonates. Zoledronic acid was associated with a reduced relative risk of a new clinical fracture and a reduction in mortality from all causes.
This trial compared yearly zoledronic acid with placebo after surgical repair of a hip fracture. Zoledronate was associated with a reduced relative risk of a new clinical fracture and a reduction in mortality from all causes.
Hip fractures are associated with increased morbidity, functional decline, and death in older adults, as well as increased use of health care services.
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Mortality is increased in the year after hip fracture, with reported rates of 15 to 25% and an estimated 9 excess deaths per 100 patients among women 70 years of age or older.
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One source of the excess morbidity and cost incurred by patients with hip fractures is new osteoporotic fractures. Such fractures occur at a rate of 10.4 per 100 patients per year, which is 2.5 times as high as the rate in age-matched . . .
IntroductionHip fractures occur 1.6 million times each year worldwide, with substantial associated mortality and losses of independence. At present, anaesthesia care for hip fracture surgery varies ...widely within and between countries, with general anaesthesia and spinal anaesthesia representing the 2 most common approaches. Limited randomised evidence exists regarding potential short-term or long-term differences in outcomes between patients receiving spinal or general anaesthesia for hip fracture surgery.MethodsThe REGAIN trial (Regional vs General Anesthesia for Promoting Independence after Hip Fracture) is an international, multicentre, pragmatic randomised controlled trial. 1600 previously ambulatory patients aged 50 and older will be randomly allocated to receive either general or spinal anaesthesia for hip fracture surgery. The primary outcome is a composite of death or new inability to walk 10 feet or across a room at 60 days after randomisation, which will be assessed via telephone interview by staff who are blinded to treatment assignment. Secondary outcomes will be assessed by in-person assessment and medical record review for in-hospital end points (delirium; major inpatient medical complications and mortality; acute postoperative pain; patient satisfaction; length of stay) and by telephone interview for 60-day, 180-day and 365-day end points (mortality; disability-free survival; chronic pain; return to the prefracture residence; need for new assistive devices for ambulation; cognitive impairment).Ethics and disseminationThe REGAIN trial has been approved by the ethics boards of all participating sites. Recruitment began in February 2016 and will continue until the end of 2019. Dissemination plans include presentations at scientific conferences, scientific publications, stakeholder engagement efforts and presentation to the public via lay media outlets.Trial registration numberNCT02507505, Pre-results.
Own the Fall: AOA Critical Issues Anderson, Paul A; Magaziner, Jay S; Mendelson, Daniel Ari ...
Journal of bone and joint surgery. American volume,
10/2021, Letnik:
103, Številka:
20
Journal Article
Recenzirano
Falls are the most common cause of injury to older patients, resulting in >3 million emergency room visits per year and 290,000 hip fractures annually in the United States. Orthopaedic surgeons care ...for the majority of these patients; however, they are rarely involved in the assessment of fall risk and providing prevention strategies. Falls also occur perioperatively (e.g., in patients with arthritis and those undergoing arthroplasty). Preoperatively, up to 40% of patients awaiting joint arthroplasty sustain a fall, and 20% to 40% have a fall postoperatively. Risk factors for falls include intrinsic factors such as age and comorbidities that are not modifiable as well as extrinsic factors, including medication reconciliation, improvement in the environment, and the management of modifiable comorbidities that can be optimized. Simple in-office fall assessment tools are available that can be adapted for the orthopaedic practice and be used to identify patients who would benefit from rehabilitation. Orthopaedic surgeons should incorporate these strategies to improve care and to reduce fall risk and associated adverse events.
Orthopedists and other clinicians assess recovery potential of hip fracture patients at 2 months post-fracture for care planning. It is unclear if examining physical performance (e.g., balance, gait ...speed, chair stand) during this follow-up visit can identify individuals at a risk of poor functional recovery, especially mobility, beyond available information from medical records and self-report.
Data came from 162 patients with hip fracture enrolled in the Baltimore Hip Studies-7th cohort. Predictors of mobility status (ability to walk 1 block at 12 months post-fracture) were the Short Physical Performance Battery (SPPB) comprising balance, walking and chair rise tasks at 2 months; baseline medical chart information (sex, age, American Society of Anesthesiologist physical status rating, type of fracture and surgery, and comorbidities); and self-reported information about the physical function (ability to walk 10 feet and 1 block at pre-fracture and at 2 months post-fracture). Prediction models of 12-month mobility status were built using two methods: (1) logistic regression with least absolute shrinkage and selection operator (LASSO) regularization, and (2) classification and regression trees (CART). Area under ROC curves (AUROC) assessed discrimination.
The participants had a median age of 82 years, and 49.3% (n = 80) were men. Two-month SPPB and gait speed were selected as predictors of 12-month mobility by both methods. Compared with an analytic model with medical chart and self-reported information, the model that additionally included physical performance measures had significantly better discrimination for 12-month mobility (AUROC 0.82 vs. 0.88, p = 0.004).
Assessing SPPB and gait speed at 2 months after a hip fracture in addition to information from medical records and self-report significantly improves prediction of 12-month mobility. This finding has important implications in providing tailored clinical care to patients at a greater risk of being functionally dependent who would not otherwise be identified using regularly measured clinical markers.
Annual infusions of zoledronic acid (5 mg) significantly reduced the risk of vertebral, hip, and nonvertebral fractures in a study of postmenopausal women with osteoporosis and significantly reduced ...clinical fractures and all‐cause mortality in another study of women and men who had recently undergone surgical repair of hip fracture. In this analysis, we examined whether timing of the first infusion of zoledronic acid study drug after hip fracture repair influenced the antifracture efficacy and mortality benefit observed in the study. A total of 2127 patients (1065 on active treatment and 1062 on placebo; mean age, 75 yr; 76% women and 24% men) were administered zoledronic acid or placebo within 90 days after surgical repair of an osteoporotic hip fracture and annually thereafter, with a median follow‐up time of 1.9 yr. Median time to first dose after the incident hip fracture surgery was ∼6 wk. Posthoc analyses were performed by dividing the study population into 2‐wk intervals (calculated from time of first infusion in relation to surgical repair) to examine effects on BMD, fracture, and mortality. Analysis by 2‐wk intervals showed a significant total hip BMD response and a consistent reduction of overall clinical fractures and mortality in patients receiving the first dose 2‐wk or later after surgical repair. Clinical fracture subgroups (vertebral, nonvertebral, and hip) were also reduced, albeit with more variation and 95% CIs crossing 1 at most time points. We concluded that administration of zoledronic acid to patients suffering a low‐trauma hip fracture 2 wk or later after surgical repair increases hip BMD, induces significant reductions in the risk of subsequent clinical vertebral, nonvertebral, and hip fractures, and reduces mortality.
Mortality rates among men are double that of women in the first 2 years after hip fracture and may be related to more infections. Research has only examined differences in short-term mortality after ...hip fracture. Thus, the objective was to determine if long-term all-cause mortality and infection-specific mortality rates are higher in men compared to women.
Data come from a prospective cohort study (Baltimore Hip Studies 7th BHS-7) with up to 10.2 years of follow-up (2006-2018). The participants were selected from eight acute care hospitals in the 25-hospital BHS network. Enrolled women were frequency-matched (1:1) to men on timing of admission for hip fracture that yielded an analytic sample size of 300 participants (155 women, 145 men). Associations between sex and mortality were analyzed using Cox proportional hazard models and cause-specific Cox models adjusted for age, cognition, body mass index, pre-fracture lower extremity activities of daily living limitation, depressive symptoms, and comorbidity.
Participants had a mean age of 80 years, 48% (n = 145) were men and the median follow-up was 4.9 (interquartile range = 2.3-8.7) years. Over the follow-up period after hospital admission for hip fracture, 237 (79.0%) participants died of all causes (132 men and 105 women) and 38 (12.7%) died of infection-specific causes (25 men and 13 women). Men had significantly higher rates of all-cause mortality hazard ratio (HR) = 2.31(95% confidence interval CI 2.02-2.59) and infection-specific mortality (HR = 4.43, CI 2.07-9.51) compared to women.
Men had a two-fold higher rate of all-cause mortality and four-fold higher rate of infection-specific mortality compared to women over a follow-up period of up to 10.2 years. Findings suggest that interventions to prevent and treat infections, tailored by sex, may be needed to narrow significant differences in long-term mortality rates between men and women after hip fracture.
Abstract
Background
We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture.
...Methods
Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness.
Results
Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of −$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of −$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant.
Conclusion
A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents.
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