Abstract 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 30 days 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 30 days 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.
Summary
Hip fractures are a serious public health issue with major consequences, especially for frail community dwellers. This study found a poor prognosis at 6 months post-trauma with regard to life ...expectancy and rehabilitation to pre-fracture independency levels. It should be realized that recovery to pre-trauma functioning is not a certainty for frail community-dwelling patients.
Introduction
Proximal femoral fractures are a serious public health issue in the older patient. Although a significant rise in frail community-dwelling elderly is expected because of progressive aging, a clear overview of the outcomes in these patients sustaining a proximal femoral fracture is lacking. This study assessed the prognosis of frail community-dwelling patients who sustained a proximal femoral fracture.
Methods
A multicenter retrospective cohort study was performed on frail community-dwelling patients with a proximal femoral fracture who aged over 70 years. Patients were considered frail if they were classified as American Society of Anesthesiologists score ≥ 4 and/or a BMI < 18.5 kg/m
2
and/or Functional Ambulation Category ≤ 2 pre-trauma. The primary outcome was 6-month mortality. Secondary outcomes were adverse events, health care consumption, rate of institutionalization, and functional recovery.
Results
A total of 140 out of 2045 patients matched the inclusion criteria with a median age of 85 (P
25
–P
75
80–89) years. The 6-month mortality was 58 out of 140 patients (41%). A total of 102 (73%) patients experienced adverse events. At 6 months post-trauma, 29 out of 120 (24%) were readmitted to the hospital. Out of the 82 surviving patients after 6 months, 41 (50%) were unable the return to their home, and only 32 (39%) were able to achieve outdoor ambulation.
Conclusion
Frail community-dwelling older patients with a proximal femoral fracture have a high risk of death, adverse events, and institutionalization and often do not reobtain their pre-trauma level of independence. Foremost, the results can be used for realistic expectation management.
Summary
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.
Quality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality ...indicators for hip fracture care reported in literature, hip fracture audits, and guidelines. The secondary aim was to compose a set of methodologically sound quality indicators for the evaluation of hip fracture care in clinical practice. A literature search according to the PRISMA guidelines and an internet search were performed to identify hip fracture quality indicators. The indicators were subdivided into process, structure, and outcome indicators. The methodological quality of the indicators was judged using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. For structure and process indicators, the construct validity was assessed. Sixteen publications, nine audits and five guidelines were included. In total, 97 unique quality indicators were found: 9 structure, 63 process, and 25 outcome indicators. Since detailed methodological information about the indicators was lacking, the AIRE instrument could not be applied. Seven indicators correlated with an outcome measure. A set of nine quality indicators was extracted from the literature, audits, and guidelines. Many quality indicators are described and used. Not all of them correlate with outcomes of care and have been assessed methodologically. As methodological evidence is lacking, we recommend the extracted set of nine indicators to be used as the starting point for further clinical research. Future research should focus on assessing the clinimetric properties of the existing quality indicators.
•The Fracture Mobility Score is a simple tool to measure mobility of hip fracture patients.•The Fracture Mobility Score has now been proven to be a valid score to measure the mobility of hip fracture ...patients.•Compared to other mobility scores the Fracture Mobility Score has a lower registration load.•The validation and the lower registration load may encourage other national hip fracture registries to start using the Fracture Mobility Score.
The Parker Mobility Score has proven to be a valid and reliable measurement of hip fracture patient mobility. For hip fracture registries the Fracture Mobility Score is advised and used, although this score has never been validated. This study aims to validate the Fracture Mobility Score against the Parker Mobility Score.
The Dutch Hip Fracture Audit uses the Fracture Mobility Score (categorical scale). For the purpose of this study, five hospitals registered both the Fracture Mobility Score and the Parker Mobility Score (0–9 scale) for every admitted hip fracture patient in 2018. The Spearman correlation between the two scores was calculated. To test whether the correlation coefficient remained stable among different patient subgroups, analyses were stratified according to baseline patient characteristics.
In total 1,201 hip fracture patients were included. The Spearman correlation between the Fracture Mobility Score and Parker Mobility Score was strong: 0.73 (p = < 0.001).
Stratified for gender, age, ASA score, dementia, Index of Activities of Daily Living (KATZ-6 ADL score), living situation and nutritional status, the correlation coefficient varied between 0.40–0.84. For patients aged 90 and over and having an ASA score of III-IV who suffered from dementia, had a KATZ-6 ADL score of 1–6, lived in an institution and/or were malnourished, the correlation was moderate.
The Fracture Mobility Score is overall strongly correlated with the Parker Mobility Score and can be considered as a valid score to measure hip fracture patient mobility. This may encourage other hip fracture audits to also use the Fracture Mobility Score, which would increase the uniformity of mobility score results among national hip fracture audits and decrease the overall registration load.
Introduction
This study aimed to evaluate the incidence of complications in elderly patients with a hip fracture following integrated orthogeriatric treatment. To discover factors that might be ...adjusted, in order to improve outcome in those patients, we examined the association between baseline patient characteristics and a complicated course.
Methods
We included patients aged 70 years and older with a hip fracture, who were treated at the Centre for Geriatric Traumatology (CvGT) at Ziekenhuisgroep Twente (ZGT) Almelo, the Netherlands between April 2011 and October 2013. Data registration was carried out using the clinical pathways of the CvGT database. Based on the American Society of Anesthesiologists (ASA) score, patients were divided into high-risk (HR, ASA 3 ≥,
n
= 341) and low-risk (LR, ASA 1–2,
n
= 111) groups and compared on their recovery. Multivariate logistic regression was used to identify risk factors for a complicated course.
Results
The analysis demonstrated that 49.6% (
n
= 224) of the patients experienced a complicated course with an in-hospital mortality rate of 3.8% (
n
= 17). In 57.5% (
n
= 196) of the HR patients, a complicated course was seen compared to 25.2% (
n
= 28) of the LR patients. The most common complications in both groups were the occurrence of delirium (HR 25.8% vs. LR 8.1%,
p
≤ 0.001), anemia (HR 19.4% vs. LR 6.3%,
p
= 0.001), catheter-associated urinary tract infections (CAUTIs) (HR 10.6% vs. LR 7.2%,
p
= 0.301) and pneumonia (HR 10.9% vs. LR 5.4%,
p
= 0.089). Independent risk factors for a complicated course were increasing age (OR 1.04, 95% CI 1.01–1.07,
p
= 0.023), delirium risk VMS Frailty score (OR 1.57, 95% CI 1.04–2.37,
p
= 0.031) and ASA score ≥3 (OR 3.62, 95% CI 2.22–5.91,
p
≤ 0.001).
Conclusions
After integrated orthogeriatric treatment, a complicated course was seen in 49.6% of the patients with a hip fracture. The in-hospital mortality rate was 3.8%. Important risk factors for a complicated course were increasing age, poor medical condition and delirium risk VMS Frailty score. Awareness of risk factors that affect the course during admission can be useful in optimizing care and outcomes. In the search for possible areas for improvement in care, targeted preventive measures to mitigate delirium, and healthcare-associated infections (HAIs), such as CAUTIs and pneumonia are important.
Summary
The AHFS
90
was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS
90
has a good accuracy and in most risk categories a good ...calibration. In our study population, the AHFS
90
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 (AHFS
90
).
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 AHFS
90
, 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 AHFS
90
includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS
90
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 AHFS
90
overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS
90
had a maximal prediction of early mortality of 64.5% in this study population.
Conclusion
The AHFS
90
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 AHFS
90
yielded a maximum prediction of early mortality of 64.5%.
Summary
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.
Summary
The nationwide Dutch Hip Fracture Audit (DHFA) is initiated to improve the quality of hip fracture care by providing insight into the actual quality of hip fracture care in daily practice. ...The baseline results demonstrate variance in practice, providing potential starting points to improve the quality of care.
Purpose
The aim of this study is to describe the development and initiation of the DHFA. The secondary aim is to describe the hip fracture care in the Netherlands at the start of the audit and to assess whether there are differences in processes at baseline between hospitals.
Methods
Eighty-one hospitals were asked to register their consecutive hip fracture patients since April 2016. In 2017, the first full calendar year, the case ascertainment was determined at audit level. Three quality indicators were used to describe and assess the care process at audit and hospital level: the proportion of completed variables at discharge and at 3 months after operation, time to surgery and orthogeriatric management.
Results
Sixty (74%) hospitals documented 14,274 patients in the DHFA by December 2017. In 2017, the case ascertainment was 58% and the average proportion of completed variables was 77%: 91% at discharge and 30% at 3 months. The median time to operation was 18 h (IQR 7–23) for American Society of Anesthesiologists score (ASA) 1–2 patients and 21 h (IQR 13–27) for ASA 3–4 patients. Of patients aged 70 years and older, 78% received orthogeriatric management. At hospital level, all three indicators showed significant practice variance.
Conclusion
Not all hospitals participate in the DHFA, and the data gathering process needs to be further optimized. However, the baseline results demonstrate an apparent variance in hip fracture practice between hospitals in the Netherlands, providing potential starting points to improve the quality of hip fracture care.
•The proactive postoperative pneumonia prevention protocol with oral care, early mobilization and intensified physical therapy, reveals promising results in the prevention of postoperative pneumonia ...after hip fracture surgery in elderly patients.•After implementation of the proactive postoperative pneumonia prevention protocol the incidence of postoperative pneumonia was significantly lower (6.7 percentage points) in the group receiving the proactive postoperative pneumonia prevention protocol (17.3% in the historical control cohort vs 10.6% in the intervention cohort; p=0.033).•The proactive postoperative pneumonia prevention protocol is considered as minimally disruptive to daily routine activities, thus lowering the barriers to their sustainable implementation and increasing the protocol's potential.
Postoperative pneumonia is among the most common complications in elderly patients after hip fracture surgery. We implemented a proactive postoperative pneumonia prevention protocol and analyzed the incidence of postoperative pneumonia in elderly patients (≥70 years of age) receiving this protocol after hip fracture surgery versus those receiving usual care before the protocol's implementation at our institution.
From November 2018 to October 2019, the proactive postoperative pneumonia prevention protocol was implemented. The treatment included intensified physical therapy, postoperative pulmonary exercises and oral care, in addition to the usual surgical treatment for elderly patients with hip fracture. The intervention cohort data were compared with a historical control cohort treated from July 2017 to June 2018. The primary outcome of this study was the incidence of postoperative pneumonia in both groups, diagnosed according to the presence of two of three of the following: elevated infection parameters, radiologic examination confirmation of pneumonia of the chest or clinical suspicion.
A total of 494 patients (n= 249 in the historical control cohort and n=245 in the intervention cohort) were included. A total of 69 patients developed postoperative pneumonia. The incidence of postoperative pneumonia was significantly lower (6.7 percentage points) in the group receiving the proactive postoperative pneumonia prevention protocol (17.3% in the historical control cohort vs 10.6% in the intervention cohort; p=0.033).
A proactive postoperative pneumonia prevention protocol showed promise in decreasing the occurrence of postoperative pneumonia after hip fracture surgery in elderly patients.
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