Influence of demographic and clinical characteristics of elderly patients with a hip fracture on mortality: A retrospective, total cohort study in North-East Spain

Predictive factors of osteoporotic hip fracture in octogenarians

OBJECTIVE

This study aims to identify the risk factors associated with osteoporotic hip fractures in octogenarians and seeks to refine primary prevention strategies for these fractures.

MATERIAL AND METHODS

We conducted a case-control study involving individuals aged 79 years and older with hip fractures, comparing them to age- and sex-matched controls without a history of hip fractures. We collected epidemiological, clinical, anthropometric, and analytical factors. We evaluated the presence of osteoporosis using bone densitometry. We defined sarcopenia according the European Working Group on Sarcopenia in Older People criteria (EWGSOP2).

RESULTS

Ninety-five patients per group were analyzed, with a mean age of 82 years, of which 74% were women. The multivariate analysis included statistically significant factors found in the univariate analysis (p < 0.05). These factors included the Barthel Index, nutritional assessment using the CONUT tool, folic acid, vitamin D deficiency, presence of previous fractures, loss of visual acuity, bicipital circumference, sarcopenia, and osteoporosis (densitometry in the neck of the femur). The Nutritional state (OR: 0.08 [0.01-0.61]), the folic acid levels (OR 0.32 [0.1-1]), and a loss of visual acuity (OR 33.16 [2.91-377.87]) were the independent risk factors associated with hip fracture.

CONCLUSIONS

The assessment of nutritional status in elderly patients, coupled with a comprehensive geriatric assessment, represents easily reproducible and cost-effective tools. These tools can effectively aid in identifying individuals at risk of hip fractures, thereby contributing to more targeted and efficient preventive measures.

Mortality following hip fracture: Trends and geographical variations over the last SIXTY years

INTRODUCTION

The management of hip fractures has advanced on all aspects from prevention pre-operatively, specialised hip fracture units, early operative intervention and rehabilitation. This is in line with the appropriate recognition over the past years of an important presentation with significant mortality and socioeconomic consequences of ever increasing incidence in an aging population. It is therefore imperative to continue to gather data on the incidence and trends of hip fractures to guide future management planning of this important presentation.

METHODS

A review of all articles published on the outcome after hip fracture over a twenty year period (1999-2018) was undertaken to determine any changes that had occurred in the demographics and mortality over this period. This article complements and expands upon the findings of a previous article by the authors assessing a four decade period (1959 - 1998) and attempts to present trends and geographical variations over sixty years.

RESULTS

The mean age of patients sustaining hip fractures continues to be steadily increasing at approximately just over 1 year of age for every 5-year time period. The mean age of patients sustaining hip fractures increased from 73 years (1960s) to 81 years (2000s) to 82 years (2010s). Over the six decade period one-year mortality has reduced from an overall mean of 27% (1960s) to 20% (2010s). The proportion of female hip fractures has decreased from 84% (1960s) to 70% (2010s). There is a decreasing trend in the proportion of intracapsular fractures from 54% (1970s) to 49% (2000s) and 48% (2010s).

CONCLUSION

Our study indicates that significant progress has been made with preventative planning, medical management, specialised orthogeriatric units and surgical urgency all playing a role in the improvements in mean age of hip fracture incidence and reduction in mortality rates. While geographical variations do still exist there has been an increase in the study of hip fractures globally with results now being published from more widespread institutions indicating appropriate increased attention and commitment to an ever-increasing presentation.

Preoperative Vitamin D Deficiency is Associated with Increased One-Year Mortality in Chinese Geriatric Hip Fracture Patients - A Propensity Score Matching Study

BACKGROUND

Vitamin D deficiency is a common comorbidity in geriatric hip fracture patients. However, there is still an ongoing debate regarding the influence of preoperative Vitamin D status on postoperative mortality in hip fracture patients.

METHODS

Elderly patients (≥60 years) who underwent surgical interventions for unilateral hip fracture from 2015 to 2020 in our center were included. We retrospectively retrieved the demographic data from the electronic medical database. Preoperative serum total 25-hydroxy-Vitamin D was set as the independent variable and patients were classified as the Vitamin D deficiency (<20ng/mL) and the control groups consequently. Clinical outcomes include all-cause mortality, walking ability, and major postoperative complications in the first postoperative year. Propensity score matching (PSM) was performed in a ratio of 1:1 in the two groups for further comparison.

RESULTS

A total of 210 patients were included and 121 patients (57.6%) were diagnosed with Vitamin D deficiency. Patients in the Vitamin D deficiency group were much older and therefore preferred peripheral nerve block, and had significantly higher proportions of females, preoperative dementia, higher ASA grade, and lower baseline serum albumin level. Overall, 79 patients were identified in the Vitamin D deficiency and control groups after PSM, respectively. Patients diagnosed with Vitamin D deficiency showed a significantly higher one-year mortality (21.5% vs 6.3%, P=0.011) and a much lower one-year independent walking rate (67.1% vs.84.8%, P=0.016) after the matching. Regarding the dataset before PSM and after PSM, the AUC for serum Vitamin D for predicting one-year mortality was 0.656 (P=0.006) and 0.695 (P=0.002), respectively.

CONCLUSION

Our retrospective PSM-design study provides new evidence that Vitamin D deficiency was associated with a significantly higher mortality and poor walking ability in the first year after surgical intervention based on southern Chinese populations.

Effects of COVID-19 confinement on the incidence and mortality of major osteoporotic fractures: an observational study in Catalonia, Spain

There is little information on how the COVID-19 lockdown influenced the epidemiology of major osteoporotic fractures (MOF). We analyzed the incidence and mortality of MOF in 2020 compared with 2018-2019 in Catalonia, Spain. The incidence of MOF decreased steeply, and post-fracture mortality increased during the lockdown and throughout 2020.

PURPOSE

To analyze the effect of the COVID-19 pandemic and lockdown on major osteoporotic fracture (MOF) incidence and mortality in Catalonia in 2020 and describe how age, sex, and the prior comorbidity burden influenced the epidemiology of MOF types.

METHODS

In this retrospective observational study, data on age and sex in people aged ≥ 50 years with a new diagnosis of MOF in 2018, 2019, and 2020 were collected. Average daily rates (ADR) were estimated overall and for five MOF: hip, distal forearm, proximal humerus, vertebrae, and pelvis. Morbidity was assessed using Adjusted Morbidity Groups. ADR in 2020 and the previous years were compared for overall and site-specific MOF in four consecutive time periods: pre-confinement, lockdown, deconfinement, and post-confinement. Thirty-day post-fracture mortality was assessed. COVID-19-related mortality was obtained from the Catalan COVID-19 register.

RESULTS

From 2018 to 2020, there were 86,412 MOF. The ADR of MOF initially increased in 2020 before the pandemic, decreased steeply during lockdown, and remained lower in the rest of the year. The decrease was steeper in vertebral, pelvic and arm fractures, and lower in hip fractures. Differences were more pronounced in younger age groups and people with fewer comorbidities. Mortality increased throughout 2020, reaching a 2.5-fold increase during lockdown. Excess mortality was directly associated with COVID-19.

CONCLUSIONS

Mobility restrictions due to COVID-19 were associated with a reduction in MOF incidence in Catalonia, especially in younger people and in non-hip fractures. Post-fracture mortality was higher than in previous years due to the high COVID-19 mortality in the elderly.

Variability in Healthcare Expenditure According to the Stratification of Adjusted Morbidity Groups in the Canary Islands (Spain)

Morbidity is the main item in the distribution of expenditure on healthcare services. The Adjusted Morbidity Group (AMG) measures comorbidity and complexity and classifies the patient into mutually exclusive clinical categories. The aim of this study is to analyse the variability of healthcare expenditure on users with similar scores classified by the AMG. Observational analytical and retrospective study. Population: 1,691,075 subjects, from Canary Islands (Spain), aged over 15 years with data from health cards, clinical history, Basic Minimum Specialised Healthcare Data Set, AMG, hospital agreements information system and Electronic Prescriptions. A descriptive, bivariant (ANOVA coefficient η²) and multivariant analysis was conducted. There is a correlation between the costs and the weight of AMG (rho = 0.678) and the prescribed active ingredients (rho = 0.689), which is smaller with age and does not exist with the other variables. As for the influence of the AMG morbidity group on the total costs of the patient, the coefficient η² (0.09) obtains a median effect in terms of the variability of expenditure, hence there is intra- and inter-group variability in the cost. In a first model created with all the variables and the cost, an explanatory power of 36.43% (R² = 0.3643) was obtained; a second model that uses solely active ingredients, AMG weight, being female and a pensioner obtained an explanatory power of 36.4%. There is room for improvement in terms of predicting the expenditure.

Epidemiology of major osteoporotic fractures: a population-based analysis in Catalonia, Spain

PURPOSE

The aim of this study was to estimate the incidence of major osteoporotic fractures in Catalonia, Spain, in 2018 and 2019 and their association with age, sex, income, climate and a set of comorbidities.

METHODS

Data on age, sex, smoking, alcohol abuse, comorbidities (obesity, Parkinson's disease, arthritis, chronic kidney disease, hepatic cirrhosis, diabetes, chronic obstructive pulmonary disease, dementia, cerebrovascular disease, hyperthyroidism, multiple myeloma and epilepsy) and income levels in people aged ≥ 50 years with a new diagnosis of major osteoporotic fractures in 2018 and 2019 were collected from the Catalan Health Surveillance System (CHSS). Climatological variables were obtained from the Catalan Meteorological Service. Incidence rates were estimated for five major osteoporotic fractures (MOF). Associations between osteoporotic fractures and age, sex, income, comorbidities and climate variables were ascertained through multilevel generalized linear model analysis (Poisson's regression).

RESULTS

There were 60,671 MOF. The annual incidence rate per 1000 persons/years at risk (PYAR) was 10.6 (3.1 for hip, 2.3 for distal forearm, 2.2 for vertebrae, 1.7 for pelvis and 1.5 for proximal humerus). Female sex, older age, lower income, smoking, alcohol abuse and some common comorbidities were associated with a higher incidence of MOF while obesity was a protective factor.

CONCLUSIONS

MOF are frequent in the adult Catalan population, especially in older women and people on low incomes. Hip fracture is the most frequent, followed by forearm and vertebral fractures. Smoking, alcohol abuse and some comorbidities were associated with an increased incidence of fracture.

Characteristics and Service Utilization by Complex Chronic and Advanced Chronic Patients in Catalonia: A Retrospective Seven-Year Cohort-Based Study of an Implemented Chronic Care Program

The Chronic Care Program introduced in Catalonia in 2011 focuses on improving the identification and management of complex chronic (CCPs) and advanced chronic patients (ACPs) by implementing an individualized care model. Its first stage is their identification based on chronicity, difficult clinical management (i.e., complexity), and, in ACPs, limited life prognosis. Subsequent stages are individual evaluation and implementation of a shared personalized care plan. This retrospective study, including all CCPs and ACPs identified in Catalonia between 2013 and 2019, was aimed at describing the characteristics and healthcare service utilization among these patients. Data were obtained from an administrative database and included sociodemographic, clinical, and service utilization variables and morbidity-associated risk according to the Adjusted Morbidity Groups (GMA) stratification. During the study period, CCPs’ and ACPs’ prevalence increased and was higher in lower-income populations; most cases were women. CCPs and ACPs had all comorbidities at higher frequencies, higher utilization of healthcare services, and were more frequently at high risk (63% and 71%, respectively) than age-, sex-, and income level-adjusted non-CCP (23%) and non-ACP populations (30%). These results show effective identification of the program’s target population and demonstrate that CCPs and ACPs have a higher burden of multimorbidity and healthcare needs.

The Analysis for Anemia Increasing Fracture Risk

Background

Fractures are a major public health problem for elderly people throughout the world. Anemia is also a common, important health problem among elderly populations. The aim of this article was to estimate the association between anemia and fracture incidence via a systematic review and meta-analysis.

Material/Methods

The participant, intervention, observation, and study design (PICOS) reporting guidelines were followed, and databases were searched from their inception to May 2020 to identify relevant studies. When heterogeneity was significant, and a random-effects model was used. Subgroup analysis was conducted to explore the source of heterogeneity based on sex, study design, and region.

Result

We found that anemia significantly increased fracture risk [relative risk (RR)=1.26, 95% confidence interval (CI)=1.14–1.39, P<0.001], specifically, hip fracture (RR=1.44, 95% CI=1.29–1.61), spine fracture (RR=1.15, 95% CI=1.08–1.23), and nonspine fracture (RR=1.42, 95% CI=1.33–1.52). Males with anemia had a 1.51-fold higher fracture risk, females had a 1.09-fold higher fracture risk. And the association was stronger in Asian (RR=1.22, 95% CI=1.07–1.40), but not in American and European study populations.

Conclusions

In conclusion, a significantly increased fracture risk was observed, and anemia can be a predictor of fracture risk.

What lies beneath: a retrospective, population-based cohort study investigating clinical and resource-use characteristics of institutionalized older people in Catalonia

Background

Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age.

Methods

Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system.

Results

This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p < 0.001 in all comparisons), IOP showed a higher annual mortality (20.46% vs. 3.13%), a larger number of chronic diseases (specially dementia: 46.47% vs. 4.58%), higher multimorbidity (15.2% vs. 4.2% with GMA of maximum complexity), and annual admissions to acute care (47.6% vs. 27.7%) and skilled nursing facilities (27.8% vs. 7.4%), mean length of hospital stay (10.0 vs. 7.2 days) and mean of medications taken (11.7 vs. 8.0).

Conclusions

There is a growing gap between the clinical and demographic characteristics of age-matched IOP and non-IOP, which overlaps with a higher mortality rate of IOP. The profile of resources utilization of IOP compared with non-IOP strongly suggests a deficiency of preventive actions and stresses the need to rethink the care model for IOP from a social and health care perspective.

Study protocol of a quasi-experimental trial to compare two models of home care for older people in the primary setting

BACKGROUND

Preventive home visits are suited for patients with reduced mobility, such as older people. Healthcare needs for older patients are expected to increase due to the extended life expectancy estimated in coming years. The implementation of low-cost, patient-centered methodologies may buffer this rise in health care costs without affecting the quality of service. In order to find the best home care model with less investment, this paper describes a study protocol comparing two models of home care for older people.

METHODS

We describe a quasi-experimental study that compares the outcome of two different home care models already implemented in two primary care centers in Badalona (Barcelona, Spain). The traditional model (control model) is integrated in the sense that is continuous, the same primary care center team looks after its assigned patients both at the center and in preventive home visits. The new functional home care model (study model), consisting of a highly trained team, is specifically designed to meet patient needs and give total attention to preventive home interventions. The study will start and end on the expected dates, June 2018 to October 2020, and include all patients over 65 years old already enrolled in the home care programs of the primary care centers selected. The primary endpoint assessed will be the difference in hospitalization days between patients included in both home care programs. Other variables regarding health status, quality of care and resource utilization will also be compared between the two models.

DISCUSSION

The study in progress will assess whether a functional and highly trained home care team will meet the ever-aging population needs in terms of cost and health outcomes better than a traditional, integrated one. Lessons learned from this pilot study will provide guidelines for a future model of home care based on the IHI Triple Aim: better care, better health, and lower costs.

TRIAL REGISTRATION

Registered in ClinicalTrials.gov (Identifier: NCT03461315; March 12, 2018).

[Mortality in a cohort of men with fragility hip fracture in a health area: Associated factors]

BACKGROUND

A quarter of the patients with fragility hip fracture (FHF) are men, and they have higher mortality rates than women. The objective of this study is to analyse the mortality, as well as associated factors, due to FHF in men aged ≥65years, while in hospital and at one and three years of follow-up.

MATERIAL AND METHODS

An analytical observational study was conducted on a historical cohort of 182 male patients equal or older than 65 years that were admitted to an Orthopaedic Surgery and Traumatology (OST) Department between January 2009 and December 2014.

RESULTS

Within-hospital mortality was 10.9% (6% in the OST Department, and 8.6% in a Social-Health centre). A relationship (P=.039) was found between within-hospital mortality and age. A total of 20 patients died during their stay in both units, 42 (25.9%) died one year later, and 95 (58.6%) died three years later. Dementia/cognitive impairment was associated with a relative risk of one-year mortality of 2.2, and 1.6 of three-year mortality. An association was observed between age and mortality and between Barthel Index at baseline and mortality at both periods. The most frequent causes of death were cardiovascular (15.7%) and tumours (13.6%).

CONCLUSIONS

Male patients with FHF showed high mortality rates in hospital, and at one-year and three-years follow-up. The most important risk factor of mortality was dementia/cognitive deterioration at one year, and high blood pressure at three years.

Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

BACKGROUND

Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

AIM

To address recent 1-year post hip fracture mortality rates in the literature.

METHODS

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

RESULTS

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

CONCLUSION

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.