Predictors of returning home after hip fracture: a prospective cohort study using the UK National Hip Fracture Database (NHFD)

Facilitating clinical trials in hip fracture in the UK : the role and potential of the National Hip Fracture Database and routinely collected data

Aims

The aim of this study was to evaluate the suitability, against an accepted international standard, of a linked hip fracture registry and routinely collected administrative dataset in England to embed and deliver randomized controlled trials (RCTs).

Methods

First, a bespoke cohort of individuals sustaining hip fractures between 2011 and 2016 was generated from the National Hip Fracture Database (NHFD) and linked to individual Hospital Episode Statistics (HES) records and mortality data. Second, in order to explore the availability and distribution of outcomes available in linked HES-Office of National Statistics (ONS) data, a more contemporary cohort with incident hip fracture was identified within HES between January 2014 and December 2018. Distributions of the outcomes within the HES-ONS dataset were reported using standard statistical summaries; descriptive characteristics of the NHFD and linked HES-ONS dataset were reported in line with the Clinical Trials Transformation Initiative recommendations for registry-enabled trials.

Results

Case ascertainment of the NHFD likely exceeds 94%. The assessment of the robustness, relevance, and reliability of the datasets was favourable. Outcomes from the HES-ONS dataset were concordant with other contemporaneous prospective cohort studies with bespoke data collection frameworks.

Conclusion

Our findings support the feasibility of the NHFD and HES-ONS to support a registry-embedded, data-enabled RCT.

In-Hospital Adverse Events in Older Patients with Hip Fracture: A Multicenter Retrospective Study

OBJECTIVES

The main objective of this study was to measure the incidence of in-hospital adverse events in older adults presenting to the emergency department (ED) with an isolated traumatic hip fracture. The secondary objective was to identify the risk factors of adverse outcomes in those patients.

DESIGN

Retrospective database analysis.

SETTING AND PARTICIPANTS

Adults aged ≥65 years presenting to 1 of the 3 Quebec level 1 adult trauma centers' ED between 2003 and 2017 with an isolated hip fracture.

METHODS

The main outcome was a composite of any adverse events defined as extended length of stay (LOS) >21 days, in-hospital complications (delirium, pressure ulcers, urinary tract infection, pneumonia, deep venous thrombosis, or pulmonary embolism), and mortality. Outcomes were also analyzed separately. Multivariable logistic regression modeling was used to identify factors associated with adverse events.

RESULTS

We included 4569 patients (female: 74.8%; mean age: 83.7 years). Low energy mechanisms were the most frequent cause of injury (68.4%), and the median LOS was 13 days (interquartile range, 8-21). A total of 1829 patients (40.0%) suffered an in-hospital adverse event: extended LOS (n = 1106; 24.2%), death (n = 365, 8.0%), and ≥1 complications (n = 892, 19.5%). Risk factors of any in-hospital adverse event included aged ≥75 years [75-84 years: adjusted odds ratio (AOR), 1.44; 95% CI, 1.17-1.76; ≥85 years: AOR, 2.11; 95% CI, 1.72-2.58], male sex (AOR, 1.35; 95% CI, 1.17-1.56), cardiovascular disease (AOR, 1.47; 95% CI, 1.23-1.77), major cognitive disorder (AOR, 1.51; 95% CI, 1.26-1.80), and ≥2 comorbidities (AOR, 1.40; 95% CI, 1.02-1.93). Direct admission from ED to the operating room was associated with decreased risk of any adverse event (AOR, 0.87; 95% CI, 0.76-0.99).

CONCLUSIONS AND IMPLICATIONS

Two out of five patients presenting to a level-1 trauma center with an isolated hip fracture suffered from an adverse event. Aged ≥75 years, male sex, cardiovascular diseases, major cognitive disorder, and ≥2 comorbidities were significant risk factors. These factors may guide early identification of high-risk patients in the ED.

Walking self-confidence and lower levels of anxiety are associated with meeting recommended levels of physical activity after hip fracture: a cross-sectional study

PURPOSE

To explore whether psychological factors are associated with ability to meet recommended physical activity thresholds after hip fracture.

MATERIALS AND METHODS

Cross-sectional observational study of 216 community-dwelling adults aged ≥65 years after hip fracture (mean age 79 SD 7 years, 70% female). Multiple ordinal regression analysis determined factors associated with meeting physical activity thresholds related to positive health outcomes: 4,400 and 7,100 daily steps. Explanatory variables were: walking self-confidence; falls self-efficacy; depression; anxiety; co-morbidities; previous gait aid use; nutritional status; age; and gender.

RESULTS

Forty-three participants (20%) met the lower threshold of ≥4,400 to <7,100 steps and thirty participants (14%) met the upper threshold of ≥7,100 steps. Walking self-confidence was positively associated with meeting higher physical activity thresholds (adjusted odds ratio [AOR] 1.32: 95% CI 1.11 to 1.57, p = 0.002). Age (AOR 0.93: 95% CI 0.89 to 0.98, p = 0.003), DASS-21 anxiety score (AOR 0.81: 95% CI 0.69 to 0.94, p = 0.008) and comorbidity index score (AOR 0.52: 95% CI 0.36 to 0.72, p < 0.001) were negatively associated with meeting higher physical activity thresholds.

CONCLUSION

Walking self-confidence and anxiety are potentially modifiable factors associated with meeting physical activity thresholds related to positive health outcomes after hip fracture.

Principles of the Orthogeriatric Model of Care: A Primer

It is well known that over the last few decades, there has been significant growth of the aging population worldwide and especially in Europe, with an increase of more than two years per decade since the 1960's. Currently, in Europe, people aged over 65 years old represent 20% of the population, creating many new and complex challenges for national healthcare systems. In many countries, geriatric medicine is an established medical specialty, integrated into the primary and secondary care of the older population. In some countries, such as Portugal, specialist training in geriatric medicine is not available, even though the life-expectancy in Portugal is currently 81 years due to a decrease in fertility and mortality, and people aged over 60 currently represent nearly a third of the population. There is strong evidence in the medical literature that a fracture following a fall, and especially a neck of femur fracture, is one of the most serious events that can happen in an older person's lifetime. These fractures have been associated with increased morbidity, loss of independence, a high rate of institutionalization, and mortality. Rates of mortality after a year from femoral fractures have been proven to be three to four times higher than the expected in the general population, ranging between 15% to 36%. This emphasizes the importance of developing well-organized care pathways for these patients, which combine specialized geriatric care (also known as orthogeriatric care). This narrative review will focus on the core principles of orthogeriatric care and how medical professionals, including those who are not specialized in geriatric care, can effectively use them.

Hip fracture projections up to the year 2060: an analysis based on data from the National Hip Fracture Database (NHFD) for England, Wales, and Northern Ireland

INTRODUCTION

Hip fractures are common and cause a huge socioeconomic burden to patients, their carers, and healthcare services worldwide. Our aim was to examine how much hip fracture numbers would be expected to rise over coming decades, simply as a consequence of the ageing of the population.

METHODS

We used data from the National Hip Fracture Database on the volume of hip fractures occurring in England, Wales and Northern Ireland in the year 2019 (n = 67,210). We projected future numbers of hip fractures by applying this number, assuming stable rates, to population growth forecast data provided by the Office for National Statistics up to the year 2060.

RESULTS

By 2060, the number of hip fractures occurring in England, Wales and Northern Ireland are projected to increase by 107 % (n = 139,105). In males, there was an estimated increase of 130 % compared with 97 % in females. There was an estimated increase across all age ranges, however the oldest age groups demonstrated the largest relative increases. The estimated increase for those aged 90 years or over was as high as 348 % and 198 % for males and females, respectively.

CONCLUSION

As a consequence of future ageing of the population, the demand on the health service posed by people with hip fracture is projected to more than double by the year 2060. Policymakers should be striving to mitigate against the huge public health impact of these projections by maximising fracture prevention strategies as far as possible and by improving the quality of hip fracture care.

Hip fracture has profound psychosocial impacts: a systematic review of qualitative studies

BACKGROUND

Hip fracture is a common and serious traumatic injury for older adults characterised by poor outcomes.

OBJECTIVE

This systematic review aimed to synthesise qualitative evidence about the psychosocial impact of hip fracture on the people who sustain these injuries.

METHODS

Five databases were searched for qualitative studies reporting on the psychosocial impact of hip fracture, supplemented by reference list checking and citation tracking. Data were synthesised inductively and confidence in findings reported using the Confidence in the Evidence from Reviews of Qualitative research approach, taking account of methodological quality, coherence, relevance and adequacy.

RESULTS

Fifty-seven studies were included. Data were collected during the peri-operative period to >12 months post fracture from 919 participants with hip fracture (median age > 70 years in all but 3 studies), 130 carers and 297 clinicians. Hip fracture is a life altering event characterised by a sense of loss, prolonged negative emotions and fear of the future, exacerbated by negative attitudes of family, friends and clinicians. For some people after hip fracture there is, with time, acceptance of a new reality of not being able to do all the things they used to do. There was moderate to high confidence in these findings.

CONCLUSIONS

Hip fracture is a life altering event. Many people experience profound and prolonged psychosocial distress following a hip fracture, within a context of negative societal attitudes. Assessment and management of psychosocial distress during rehabilitation may improve outcomes for people after hip fracture.

Association between institutionalization by 4 months post-discharge walking capacity and lean body mass in elderly hip fracture patients: Evidence from a Swedish Registry Based Study

Background and purpose

Losing independence is a main concern for hip fracture patients, and particularly not being able to return home. Given the large impact on quality of life by loss of independence and the high risk for institutionalization after hip fracture, it is of importance to identify modifiable risk factors for such negative outcomes. This study aimed to investigate the association between two such factors, that is, lean body mass and 4 months post-discharge walking capacity, and the risk of institutionalization in previously independent living older people who suffer a hip fracture.

Patients and methods

A retrospective cohort study was conducted using Swedish national-based population registers. Patients ⩾60 years with a hip fracture during 2008-2017 were included from the Swedish National Registry for Hip Fractures. Risk of institutionalization over the 1-year period following a hip fracture was analyzed using logistic regression analyses adjusted for potential predictors and characteristics.

Results

In total, 11,265 patients were included. Over the first year, 8% (95% CI: 8-9) of the patients with a hip fracture had lost independence, increasing to 15% (95% CI: 14-16) after 5 years. Poor recovery of post-discharge walking ability was associated with a higher odds ratio of losing independence compared with good recovery (OR 12.0; 95% CI: 7.8-18.4; p < 0.001). Having higher estimated lean body mass than 45 kg at index was associated with lower odds of losing independence.

Conclusion

Maintaining lean body mass and mobility after a hip fracture is likely important from an individual as well as public health perspective.

Cognitive assessment to optimize prediction of functional outcome in subacute hip fracture: a short-term prospective study

BACKGROUND

Cognitive impairment is a long-known negative prognostic factor after hip fracture. Cognition is usually screened by a single easy-to-administer bedside tool, but recent studies have shown that screening tests may be not enough to rule out cognitive impairment with an unfavorable prognostic role. Unfortunately, data on outcome prediction by further cognitive assessments is sparse.

AIM

We focused on patients with subacute hip fracture defined cognitively intact or mildly impaired on the screening evaluation performed by the Short Portable Mental Status Questionnaire (SPMSQ). We hypothesized that each of 3 further cognitive tests could independently predict activities of daily living, with optimal prediction of function obtained by performing all three the tests.

DESIGN

Short-term prospective study.

SETTING

Rehabilitation ward.

POPULATION

Inpatients with subacute hip-fracture.

METHODS

Three cognitive tests were performed on admission to rehabilitation in the patients who made ≤4 errors on the SPMSQ: Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning Test (RAVLT, immediate and delayed recall) and Frontal Assessment Battery (FAB). We assessed activities of daily living by the Barthel index. Successful rehabilitation was defined with a Barthel Index Score ≥85.

RESULTS

Each of the three cognitive tests assessed before rehabilitation significantly predicted the Barthel index scores measured at the end of the rehabilitation course in our sample of 280 inpatients. However, only the MoCA score retained its significant predictive role when the scores from the three tests were included together as independent variables in a multiple regression model, with adjustments for a panel of potential confounders (P=0.007). The adjusted odds ratio to achieve successful rehabilitation for a seven-point change in MoCA score was 1.98 (CI 95% from 1.02 to 3.83; P=0.042).

CONCLUSIONS

Contrary to our hypothesis, MoCA but not RAVLT and FAB retained the prognostic role when the scores from the three tests were evaluated together as potential predictors of functional ability in activities of daily living.

CLINICAL REHABILITATION IMPACT

In the presence of a normal (or mildly altered) score on the SPMSQ in subacute hip fracture, MoCA scores improve prediction of activities of daily living and should be routinely performed.

Delirium in hip fracture patients admitted from home during the COVID-19 pandemic is associated with higher mortality, longer total length of stay, need for post-acute inpatient rehabilitation, and readmission to acute services

Aims

Delirium is associated with adverse outcomes following hip fracture, but the prevalence and significance of delirium for the prognosis and ongoing rehabilitation needs of patients admitted from home is less well studied. Here, we analyzed relationships between delirium in patients admitted from home with 1) mortality; 2) total length of hospital stay; 3) need for post-acute inpatient rehabilitation; and 4) hospital readmission within 180 days.

Methods

This observational study used routine clinical data in a consecutive sample of hip fracture patients aged ≥ 50 years admitted to a single large trauma centre during the COVID-19 pandemic between 1 March 2020 and 30 November 2021. Delirium was prospectively assessed as part of routine care by the 4 A's Test (4AT), with most assessments performed in the emergency department. Associations were determined using logistic regression adjusted for age, sex, Scottish Index of Multiple Deprivation quintile, COVID-19 infection within 30 days, and American Society of Anesthesiologists grade.

Results

A total of 1,821 patients were admitted, with 1,383 (mean age 79.5 years; 72.1% female) directly from home. Overall, 87 patients (4.8%) were excluded due to missing 4AT scores. Delirium prevalence in the whole cohort was 26.5% (460/1,734): 14.1% (189/1,340) in the subgroup of patients admitted from home, and 68.8% (271/394) in the remaining patients (comprising care home residents and inpatients when fracture occurred). In patients admitted from home, delirium was associated with a 20-day longer total length of stay (p < 0.001). In multivariable analyses, delirium was associated with higher mortality at 180 days (odds ratio (OR) 1.69 (95% confidence interval (CI) 1.13 to 2.54); p = 0.013), requirement for post-acute inpatient rehabilitation (OR 2.80 (95% CI 1.97 to 3.96); p < 0.001), and readmission to hospital within 180 days (OR 1.79 (95% CI 1.02 to 3.15); p = 0.041).

Conclusion

Delirium affects one in seven patients with a hip fracture admitted directly from home, and is associated with adverse outcomes in these patients. Delirium assessment and effective management should be a mandatory part of standard hip fracture care.

Risk Factors and 120-day Functional Outcomes of Delirium After Hip Fracture Surgery: A Prospective Cohort Study Using the UK National Hip Fracture Database (NHFD)

OBJECTIVES

To identify risk factors of postoperative delirium among patients with hip fracture with normal preoperative cognition, and examine associations with returning home or recovery of mobility.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

We used the National Hip Fracture Database (NHFD) to identify patients presenting with hip fracture in England (2018-2019), but excluded those with abnormal cognition (abbreviated mental test score [AMTS] < 8) on presentation.

METHODS

We examined the results of routine delirium screening performed using the 4 A's Test (4AT), to assess alertness, attention, acute change, and orientation in a 4-item mental test. Associations between 4AT score and return home or to outdoor mobility at 120 days were estimated, and risk factors identified for abnormal 4AT scores: (1) 4AT ≥4 suggesting delirium and (2) 4AT = 1-3 being an intermediate score not excluding delirium.

RESULTS

Overall, 63,502 patients (63%) had a preoperative AMTS ≥8, in whom a postoperative 4AT score ≥4 suggestive of delirium was seen in 4454 (7%). These patients were less likely to return home (odds ratio [OR], 0.46; 95% CI, 0.38-0.55) or regain outdoor mobility (OR, 0.63; 95% CI, 0.53-0.75) by 120 days. Multiple factors including any deficit in preoperative AMTS and malnutrition were associated with higher risk of 4AT ≥4, while use of preoperative nerve blocks was associated with lower risk (OR, 0.88; 95% CI, 0.81-0.95). Poorer outcomes were also seen in 12,042 (19%) patients with 4AT = 1-3; additional risk factors associated with this score included socioeconomic deprivation and surgical procedure types that were not compliant with National Institute of Health and Care Excellence guidance.

CONCLUSION AND IMPLICATIONS

Delirium after hip fracture surgery significantly reduces the likelihood of returning home or to outdoor mobility. Our findings underline the importance of measures to prevent postoperative delirium, and aid the identification of high-risk patients for whom delirium prevention might potentially improve outcomes.