Time of admission and mortality after hip fracture: a detailed look at the weekend effect in a nationwide study of 55,211 hip fracture patients in Norway

Orthogeriatric care-outcome of different fragility fractures

INTRODUCTION

Fragility fractures (FF) are associated with increased morbidity and mortality and reflect a dramatic turning point in the life of older adults. The scientific discourse is dominated by proximal femoral fractures, but FF affect multiple parts of the body and often precede hip fractures. Orthogeriatric co-management has multiple shown to improve patient's outcome. We hypothesize that all geriatric patients with FF benefit from orthogeriatric co-management.

MATERIALS AND METHODS

We retrospectively evaluated all patients over 70 years with FF (hip joint, periprosthetic, spine, pelvic ring, and humerus) of our geriatric trauma center for the years 2019-2021, who received orthogeriatric co-management. Demographic data, fracture type, complications, discharge modality and in-hospital mortality were recorded. For patients transferred to geriatrics, the Barthel Index (BI) and the discharge modality were recorded. Primary outcome parameters were discharge modality and BI difference. Secondary outcome parameters were complication rates and in-hospital mortality. Logistic regression analysis was performed.

RESULTS

555 patients (83.8 ± 6.5 years, 182 males, 373 females) were evaluated. 245 (44.1%) patients were referred to geriatrics for further orthogeriatric treatment. Positive predictors were age, surgery, and a high Charlson Comorbidity Index. The overall in-hospital mortality was 8.6% (n = 48) (5.8% (n = 32) during acute trauma care and 6.5% (n = 16) during stay in geriatrics). The mortality rate of nursing home residents was significantly higher compared to patients living at home (10.4% vs. 5.6%). The rate of non-surgical complications was 44.5%. 26.9% of patients living at home were discharged to a nursing home, while 51.3% were able to return home. The risk of admission to a nursing home was reduced for thoracolumbar fractures (OR = 0.22) and increased markedly for periprosthetic fractures (OR = 3.95). During orthogeriatric treatment, all fractures showed a significant increase in BI. Patients living at home benefited more than nursing home residents (20.5 ± 19.5 vs. 8.7 ± 18.0 points). The chance of a BI increase (> 19 points) was increased for hip and pelvic ring fractures. Devastating results showed patients with dementia. In comparison, mentally healthy patients had a 4.5-fold increased chance of increasing their BI (> 19 points).

CONCLUSIONS

Presented data shows that all patients with FF are at high risk for complications and could benefit from standardized orthogeriatric management. Modern patient care requires a holistic orthogeriatric approach to improve patient's outcome.

How do busy hospital circumstances affect mortality and readmission within 60 days: A cohort study of 680 000 acute admissions in Norway

OBJECTIVE

To study mortality and readmissions for older patients admitted during more and less busy hospital circumstances.

DESIGN

Cohort study where we identified patients that were admitted to the same hospital, during the same month and day of the week. We estimated effects of inflow of acute patients and the number of concurrent acute inpatients. Mortality and readmissions were analysed using stratified Cox-regression.

SETTING

All people 80 years and older acutely admitted to Norwegian hospitals between 2008 and 2016.

MAIN OUTCOME MEASURES

Mortality and readmissions within 60 days from admission.

RESULTS

Among 294 653 patients with 685 197 admissions, mean age was 86 years (standard deviation 5). Overall, 13% died within 60 days. An interquartile range difference in inflow of acute patients was associated with a hazard ratio (HR) of 0.99, 95% confidence interval (95% CI) 0.98 to 1.00). There was little evidence of differences in readmissions, but a 7% higher risk (HR 1.07, 95% CI 1.06 to 1.09) of being discharged outside ordinary daytime working hours.

CONCLUSIONS

Older patients admitted during busier circumstances had similar mortality and readmissions to those admitted during less busy periods. Yet, they showed a higher risk of discharge outside daytime working hours. Despite limited effects of busyness on a hospital level, there could still be harmful effects of local situations.

Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery

INTRODUCTION

Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients.

METHODS

All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression.

RESULTS

Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday.

CONCLUSION

With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

Access to care for low trauma hip fractures in South Africa

RATIONALE

Early surgery is recommended for hip fractures.

MAIN RESULT

In this study only one-third of subjects with hip fractures were admitted within 24 h of the fracture, and surgery was delayed beyond 48 h in the majority.

SIGNIFICANCE

These findings highlight the need to improve access to care for hip fracture subjects.

PURPOSE

There is limited data on the timing of admission and surgery following a low trauma hip fracture (HF) in South Africa (SA).

METHODS

A prospective, observational study was conducted at public and private hospitals in three provinces, Gauteng (GP), KwaZulu-Natal (KZN) and the Western Cape (WC), in SA to determine time from fracture to admission and from admission to surgery in patients presenting with low trauma HF. Associations with delayed admission and surgery were explored using logistic regression.

RESULTS

The median age of the 1996 subjects was 73 years (IQR 63-81 years), the majority were women (1346, 67%) and 1347 (67%) were admitted to the public hospitals. In one-third of subjects (661, 33%), admission was delayed to beyond 24 h after the fracture. There was a significantly longer time to admission in public compared to private hospitals (21 h [IQR 10.0-48.5] versus 6 h [IQR 3.3-14.1], p < 0.001), in subjects < 65 years, the WC and when admission occurred on a weekday. Surgery was delayed beyond 48 h in the majority (1272, 69%) of subjects and was significantly longer in public compared to private hospitals (130 h [IQR 62.6-212.4] versus 45.4 h [IQR 24.0-75.5], p < 0.001), in KZN, and when admission occurred after hours.

CONCLUSION

The burden of HFs is higher at public hospitals in SA, where there is a significant delay in admission after a fracture and surgery after admission. This highlights the need for a review of HF care pathways, resources and policies.

Is There a "Weekend Effect" in Intertrochanteric Fracture Surgery?

INTRODUCTION

Numerous studies reported poorer outcomes for patients who were admitted at weekends or off-hour, which relates to the underlying concept called the "weekend effect." We aimed to assess the effect of adverse outcomes in older patients with intertrochanteric fracture surgery.

METHODS

A retrospective cohort study of patients aged ≥65 years with intertrochanteric fracture surgery. Data were collected from computerized medical records and all patients had a long-term follow-up. The association between weekend effect with adverse outcomes and factors for all-cause mortality was studied by 3-group comparison, Spearman and partial correlation analysis, univariate analysis, and multivariate Cox proportional-hazard model.

RESULTS

Our results showed no evidence supporting the existence of a weekend effect on adverse outcomes, including mortality rates (p = 0.950, log-rank), length of hospital stay, total hospital costs, rate and volume of transfusion, visual analog scale score, Harris Hip Score, and specific complications (all p > 0.05), except for an average of 0.5 days longer surgical delay found in patients admitted on Fridays relative to other days (p = 0.013). Instead, only age group (with a 10-year interval, HR 1.43, 1.28-1.59 95% CI, p < 0.001) and surgical delay (HR 1.05, 1.02-1.07 95% CI, p < 0.001) were identified as significantly associated with all-cause mortality.

CONCLUSIONS

Older patients with intertrochanteric fracture surgery have similar mortality and adverse outcomes rates when admitted on weekends or holidays compared with weekdays. Our findings suggest that collaborative multidisciplinary team care seems both effective and efficient in the management of older patients with intertrochanteric fractures on any day of the week.

Association between hospital surgical volume and complications after total hip arthroplasty in femoral neck fracture: A propensity score-matched cohort study

BACKGROUND

For displaced femoral neck fractures (FNF), total hip arthroplasty (THA) or hemiarthroplasty (HA) is preferred rather than fracture fixation. THA for patients with FNF requires skilled operators since patient with FNF likely to have osteoporosis and a higher risk of complications. Several reports suggest that higher hospital surgical volume was associated with a lower risk of complications after THA for osteoarthritis. However, little is known concerning this association with THA for FNF. Herein, we investigated the association between THA and complication and the recovery of physical function after THA to optimize the quality of FNF.

METHODS

A nationwide retrospective cohort study of elderly undergoing THA between April 1, 2011, to March 31, 2018 was performed. The association between hospital surgical volume and complication after THA for FNF was visually described with the restricted cubic spline regression analysis. Then the risk of complications was quantified with propensity score matching analysis based on the cutoff point identified by the restricted cubic spline curve. Primary outcome was secondary revision surgery, and the secondary outcomes included surgical and systemic complications, and the recovery of physical function at hospital discharge.

RESULTS

By visualization of the spline curve, we identified 20 cases per year as cutoff point of low hospital surgical volume. Following 1,396 patients' propensity score-match analysis (mean age 75.2 [SD] 8.8, female 80.4%), the risk of secondary revision surgery was significantly higher among the low hospital surgical volume group (absolute risk difference (RD), 2.44%; p = 0.011). Also, the incidence of blood transfusion was higher in the low hospital surgical volume group (RD, 4.01%; p = 0.049). However, there was no significant difference in the recovery of the transferring and walking ability at discharge between high and low hospital surgical volume groups (63.5% vs 62.6%, 58.5% vs 57.5%; p = 0.74, 0.71, respectively).

CONCLUSION

Our research demonstrated that an increase in hospital surgical volume significantly reduced the incidence of secondary revision surgery after a certain inflection point, but not significantly improved short-term physical functions.

A new preoperative risk score for predicting mortality of elderly hip fracture patients: an external validation study

BACKGROUND

Hip fractures are common in the elderly and have a high risk of mortality. Several risk prediction models for mortality of hip fracture have been developed, but most of them are difficult to apply accurately in clinical practice.

AIMS

The objective of the present study was to perform an external validation of a new published preoperative risk score for predicting mortality.

METHODS

We carried out a retrospective cohort study from January 2014 to December 2018 for elderly hip fracture patients discharged from a orthopedic center in China. The preoperative risk score was calculated for each patient, and further divided into two groups: low-risk group (score < 24 points) and high-risk group (score ≥ 24 points) using the receiver operating characteristic (ROC) curve. The outcome was 30-day, 6-month and 1-year all-cause mortality, and the relationship between the risk score and mortality was assessed by univariate and multivariate Cox proportional hazard models. The area under the curve (AUC), Hosmer-Lemeshow test and calibration plots were used to test the discrimination and calibration.

RESULTS

A total of 460 consecutive patients were included in the study, and high-risk score was an independent risk factor for 30-day mortality [Hazard ratio (HR) 6.70; 95% Confidence interval (CI) 1.82-24.69; p = 0.004], 6-month mortality (HR 2.94; 95% CI 1.68-5.17; p < 0.001) and 1-year mortality (HR 3.30; 95% CI 2.09-5.20; p < 0.001). Also, each point increase in the risk score resulted in a 11% increase in 30-day mortality (HR 1.11; 95% CI 1.07-1.16; p < 0.001), 6% increase in 6-month mortality (HR 1.06; 95% CI 1.04-1.09; p < 0.001), and 5% increase in 1-year mortality (HR 1.05; 95% CI 1.03-1.07; p < 0.001). Moreover, the risk score had an AUC of 0.89 (95% CI 0.80-0.98) for 30-day mortality, 0.77 (95% CI 0.70-0.83) for 6-month mortality, and 0.76 (95% CI 0.70-0.81) for 1-year mortality. Calibration plots showed a good calibration between observed and predicted mortality, which was also demonstrated by the Hosmer-Lemeshow test.

CONCLUSION

Our present study findings indicated that the preoperative risk score was an accurate mortality risk assessment tool for elderly hip fracture patients, regardless of short- and long-term follow-up.

High volumes of recent surgical admissions, time to surgery, and 60-day mortality

AIMS

Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients.

METHODS

This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions.

RESULTS

Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75^th percentile) proportion of recent surgical admission compared to a low (25^th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4).

CONCLUSION

A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264-270.

Effect of weekend admission on geriatric hip fractures

BACKGROUND

The care discrepancy for patients presenting to a hospital on the weekend relative to the work week is well documented. With respect to hip fractures, however, there is no consensus about the presence of a so-called “weekend effect”. This study sought to determine the effects, if any, of weekend admission on care of geriatric hip fractures admitted to a large tertiary care hospital. It was hypothesized that geriatric hip fracture patients admitted on a weekend would have longer times to medical optimization and surgery and increased complication and mortality rates relative to those admitted on a weekday.

AIM

To determine if weekend admission of geriatric hip fractures is associated with poor outcome measures and surgical delay.

METHODS

A retrospective chart review of operative geriatric hip fractures treated from 2015-2017 at a large tertiary care hospital was conducted. Two cohorts were compared: patients who arrived at the emergency department on a weekend, and those that arrived at the emergency department on a weekday. Primary outcome measures included mortality rate, complication rate, transfusion rate, and length of stay. Secondary outcome measures included time from emergency department arrival to surgery, time from emergency department arrival to medical optimization, and time from medical optimization to surgery.

RESULTS

There were no statistically significant differences in length of stay (P = 0.2734), transfusion rate (P = 0.9325), or mortality rate (P = 0.3460) between the weekend and weekday cohorts. Complication rate was higher in patients who presented on a weekend compared to patients who presented on a weekday (13.3% vs 8.3%; P = 0.044). Time from emergency department arrival to medical optimization (22.7 h vs 20.0 h; P = 0.0015), time from medical optimization to surgery (13.9 h vs 10.8 h; P = 0.0172), and time from emergency department arrival to surgery (42.7 h vs 32.5 h; P < 0.0001) were all significantly longer in patients who presented to the hospital on a weekend compared to patients who presented to the hospital on a weekday.

CONCLUSION

This study provided insight into the “weekend effect” for geriatric hip fractures and found that day of presentation has a clinically significant impact on delivered care.

Analysis of weekend effect on mortality by medical specialty in Helsinki University Hospital over a 14-year period

BACKGROUND

The weekend effect, the phenomenon of patients admitted at the weekend having a higher mortality risk, has been widely investigated and documented in both elective and emergency patients. Research on the issue is scarce in Europe, with the exception of the United Kingdom. We examined the situation in Helsinki University Hospital over a 14-year period from a specialty-specific approach.

MATERIALS AND METHODS

We collected the data for all patient visits for 2000-2013, selecting patients with in-hospital care in the university hospital and extracting patients that died during their hospital stay or within 30 days of discharge. These patients were categorized according to urgency of care and specialty.

RESULTS

A total of 1,542,230 in-patients (853,268 emergency patients) met the study criteria, with 47,122 deaths in-hospital or within 30 days of discharge. Of 12 specialties, we found a statistically significant weekend effect for in-hospital mortality in 7 specialties (emergency admissions) and 4 specialties (elective admissions); for 30-day post-discharge mortality in 1 specialty (emergency admissions) and 2 specialties (elective admissions). Surgery, internal medicine, neurology, and gynecology and obstetrics were most sensitive to the weekend effect.

CONCLUSIONS

The study confirms a weekend effect for both elective and emergency admissions in most specialties. Reducing the number of weekend elective procedures may be necessary. More disease-specific research is needed to find the diagnoses most susceptible.

Quality assessment of weekend discharge: a systematic review and meta-analysis

PURPOSE

Hospital bed utility and length of stay affect the healthcare budget and quality of patient care. Prior studies already show admission and operation on weekends have higher mortality rates compared with weekdays, which has been identified as the 'weekend effect.' However, discharges on weekends are also linked with quality of care, and have been evaluated in the recent decade with different dimensions. This meta-analysis aims to discuss weekend discharges associated with 30-day readmission, 30-day mortality, 30-day emergency department visits and 14-day follow-up visits compared with weekday discharges.

DATA SOURCES

PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched from January 2000 to November 2019.

STUDY SELECTION

Preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Only studies published in English were reviewed. The random-effects model was applied to assess the effects of heterogeneity among the selected studies.

DATA EXTRACTION

Year of publication, country, sample size, number of weekday/weekend discharges, 30-day readmission, 30-day mortality, 30-day ED visits and 14-day appointment follow-up rate.

RESULTS OF DATA SYNTHESIS

There are 20 studies from seven countries, including 13 articles from America, in the present meta-analysis. There was no significant difference in odds ratio (OR) in 30-day readmission, 30-day mortality, 30-day ED visit, and 14-day follow-up between weekday and weekend. However, the OR for 30-day readmission was significantly higher among patients in the USA, including studies with high heterogeneity.

CONCLUSION

In the USA, the 30-day readmission rate was higher in patients who had been discharged on the weekend compared with the weekday. However, interpretation should be cautious because of data limitation and high heterogeneity. Further intervention should be conducted to eliminate any healthcare inequality within the healthcare system and to improve the quality of patient care.

Factors associated with one-year mortality of patients admitted with fragility hip fracture: a follow-up study in Southern Sri Lanka

One hundred and eighty patients with incident fragility hip fracture admitted to a tertiary care center in Sri Lanka were followed up for 12 months. When compared with those survived, patients who died were older and had higher comorbidity and physical impairment, before fracture and at discharge from the hospital.

INTRODUCTION

This study examined the factors that are associated with mortality within the first 12 months, of patients admitted with fragility hip fracture to a tertiary care center in Southern Sri Lanka.

METHODS

One hundred and eighty consecutive patients admitted with new fragility hip fracture were followed up for 12 months post-fracture. Apart from age and gender, information related to physical dependency (prefracture and at discharge) and comorbidity were collected from all subjects.

RESULTS

Of 180 patients (149women), 107 had surgery while the rest were managed conservatively. Mean (SD) age of study subjects was 76.5 (9.2 years). Thirty-three patients died within the first 12 months were older and had higher comorbidity and physical impairment before fracture and at discharge from the hospital, when compared with those survived. Relative risk (95% CI, p value) of death for being a male was 6.52 (3.18-11.5, < 0.001) and corresponding values for conservative management were 6.59 (2.86-15.2, < 0.001). In the ROC analysis, in which mortality/survival was taken as state variable, AUCs for age, Charlson index, age-adjusted Charlson index, and Barthel index before fracture and Barthel index at discharge were 0.77 (0.04), 0.79 (0.04), 0.70 (0.05), 0.67 (0.05), and 0.76 (0.04 ) (p < 0.01 for all). Age-adjusted odd ratios (95% CI) of ACCI, CCI, surgical management, and Barthel index before fracture and at discharge were 2.21 (1.37 to 3.57), 2.37 (1.46 to 3.83), 0.18 (0.06 to 0.53), 0.91 (0.85 to 0.97), and 0.93 (0.88 to 0.99), respectively (p < 0.05 for all).

CONCLUSIONS

We conclude that advanced age, male gender, higher comorbidity, physical impairment before and after fracture, and conservative management lead to a higher risk of mortality in patients admitted with incident fragility hip fracture. This study can be used as a platform for future research in this area in Sri Lanka.

Weekend effect on mortality by medical specialty in six secondary hospitals in the Helsinki metropolitan area over a 14-year period

BACKGROUND

The weekend effect is the phenomenon of a patient's day of admission affecting their risk for mortality. Our study reviews the situation at six secondary hospitals in the greater Helsinki area over a 14-year period by specialty, in order to examine the effect of centralization of services on the weekend effect.

METHODS

Of the 28,591,840 patient visits from the years 2000-2013 in our hospital district, we extracted in-patients treated only in secondary hospitals who died during their hospital stay or within 30 days of discharge. We categorized patients based on the type of each admission, namely elective versus emergency, and according to the specialty of their clinical service provider and main diagnosis.

RESULTS

A total of 456,676 in-patients (292,399 emergency in-patients) were included in the study, with 17,231 deaths in-hospital or within 30 days of discharge. A statistically significant weekend effect was observed for in-hospital and 30-day post-discharge mortality among emergency patients for 1 of 7 specialties. For elective patients, a statistically significant weekend effect was visible in in-hospital mortality for 4 of 8 specialties and in 30-day post-discharge mortality for 3 of 8 specialties. Surgery, internal medicine, and gynecology and obstetrics were most susceptible to this phenomenon.

CONCLUSIONS

A weekend effect was present for the majority of specialties for elective patients, indicating a need for guidelines for these admissions. More disease-specific research is necessary to find the diagnoses, which suffer most from the weekend effect and adjust staffing accordingly.

Is there a weekend effect after hip fracture surgery? A study of 74,410 hip fractures reported to the Norwegian Hip Fracture Register

Background and purpose - The term "weekend effect" describes differences in outcomes between patients treated at weekends compared with weekdays. We investigated whether there is a weekend effect for the risk of reoperation and mortality after hip fracture surgery at Norwegian hospitals.Patients and methods - We included data from 76,410 hip fractures in patients 60 years and older reported to the Norwegian Hip Fracture Register (NHFR) between 2005 and 2017. Cox survival analyses with adjustments for age, sex, ASA class, type of fracture, operating method, and waiting time from fracture to surgery were used to calculate the risk of reoperation and death after surgeries performed at weekends compared with surgeries performed on weekdays.Results - The mean age for all patients was 82 years, and 71% were female. 73% of fractures occurred on weekdays (Monday to Friday) and 27% during weekends (Saturday and Sunday). 71% of fractures were operated on a weekday and 29% at a weekend. Slightly increased mortality was observed during the 2 first months after weekend admission with hip fracture (HR 1.08; 95% CI 1.03-1.14). This did not continue in subsequent months, but the initial effect of weekend presentation was still apparent at 1-year follow-up. Further, there was no difference in mortality between patients who were operated at a weekend and patients operated on a weekday. Neither were there any differences in the risk of reoperation between weekday and weekend when comparing day of fracture or day of surgery.Interpretation - Patients who suffered a hip fracture during a weekend had slightly increased mortality in the first 2 months postoperatively. Whether the surgery was done on weekdays or at weekends did not affect mortality or the risk of reoperation.