Factors influencing length of stay and mortality after first and second hip fractures: an event modeling analysis

Outcomes and Risks Associated With Subsequent Contralateral Hip Fractures

BACKGROUND

Hip fractures constitute a major public health problem for older individuals. They are associated with functional deterioration, limited mobility, and increased mortality, while contributing to economic and social hardships that are compounded by a second hip fracture. With the aging US population and increasing rates of hip fractures, it is essential to understand factors surrounding subsequent contralateral hip fractures.

MATERIALS AND METHODS

This descriptive study was a retrospective review of patients 60 years and older who were identified in the institutional geriatric hip fracture database as having had an initial and subsequent contralateral hip fracture, with the second treated at our tertiary referral center.

RESULTS

The incidence of subsequent hip fracture was 13.2%. The mean time to second hip fracture was 3.5 years after the initial injury. The first fracture tended to be a femoral neck fracture, whereas the second injury was more likely to have an intertrochanteric pattern. There was a higher complication rate after a subsequent hip fracture. Patients taking osteoporosis and adjuvant medication prior to admission for the second fracture tended to have a lower 90-day mortality rate. Patients with a history of any fracture prior to the first hip fracture, with cancer, and with osteopenia had shorter intervals to the subsequent event.

CONCLUSION

Subsequent hip fractures carry high morbidity and mortality rates. Steps should be taken after the initial injury to optimize outcomes in the case of a subsequent event. Patients discharged after initial hip fracture should be maintained with osteoporosis medication. [Orthopedics. 2024;47(5):264-269.].

Does the ASA grading influence the outcomes of best practice tariff in fracture neck of femurs

Objectives:

The aim of this study is to find the significance of different ASA grades in achieving the Best Practice Tariff (BPT) and their outcomes in patients with fracture neck of femur.

Methods:

A retrospective study over a five years period. Patient demographics, ASA grading, hospital admission timing, time to theatre and discharge date were recorded. The 30 day mortality rate and length of stay were calculated for each ASA grades for patients who met and failed BPT.

Results:

1798 patients were included in the study. 54% was ASA grade 3, grade 4 represented 22% and grade 2, 19%. The mean AMT score was 6.4 who met BPT and 4.4 who failed BPT (p<0.001). 319 patients with ASA≤2 met BPT and 53 patients failed to meet BPT. In ASA ≥3, 1200 patients who met BPT and 225 patients failed BPT. The 30-day mortality in patients with ASA≤2 who met BPT was 2.57% and those who failed were 1.92%. In ASA ≥3 the 30-day mortality was 12.63% and who failed BPT was 25% which is statistically significant.

Conclusion:

In patients with ASA≥3 the 30-day mortality is significantly higher in those who failed BPT compared to ASA≤2 patients whether they achieved BPT or not.

Early Clinical Outcomes of Short versus Long Proximal Femoral Nail Anti-rotation (PFNA) in the Treatment of Intertrochanteric Fractures

INTRODUCTION

Both short and long PFNA are employed to treat intertrochanteric fractures. Controversy exists in the choice between the two nails as each implant has specific characteristics and theoretical advantages. This retrospective study seeks to examine the operative complication rates and clinical outcomes of short versus long (Proximal Femoral Nail Antirotation) PFNA in the treatment of intertrochanteric fractures.

MATERIAL AND METHODS

Between July 2011 and February 2015, 155 patients underwent PFNA insertion. The decision on whether to use a short or long PFNA nail, locked or unlocked, was determined by the attending operating surgeon. Visual Analogue Pain Score (VAS) Harris Hip Scores (HHS), Short-form 36 Health Questionnaire (SF-36) and Parker Mobility Scores (PMS) were collected at six weeks, six months and one year post-operatively.

RESULTS

A total of 137 (88.4%) patients were successfully followed-up. Forty-two (30.7%) patients received a short PFNA. The patients were similar in baseline characteristics of age, gender, and comorbidities. Operative time was significantly longer in the short PFNA group (62 ±17 mins) versus the long PFNA group (56±17). While the patients in both groups achieved improvement in all outcome measures, there was no significant difference between the groups in terms of HHS (61.0 ±16.0 vs 63.0 ±16.8, p=0.443), PMS (2.3±1.5 vs 2.7±2.1, p=0.545) and VAS (1.7±2.9 vs 1.8 ±2.2 p=0.454). There were 3 (7.1%) and 7 (7.4%) complications in the short versus long PFNA group, respectively.

CONCLUSION

Both short and long PFNA had similar clinical outcomes and complication rates in the treatment of intertrochanteric fractures in an Asian population.

Instrumental Activities of Daily Living-A Good Tool to Prospectively Assess Disability after a Second Contralateral Hip Fracture?

The aim of this study was to determine the outcome for patients who sustain a second hip fracture compared with those who sustain a first fracture, and to define the optimal measure to evaluate functional outcome after second hip fracture. Methods: 343 patients with acute hip fractures who presented during a 12 month period were included in the study. Patients with a first (318 patients, 78.10 +/− 7.53 years) and second (25 patients, 78.96 +/− 6.02) hip fracture were compared regarding all baseline variables. Regression analysis was also performed to assess the independent relationship between the presence of a second hip fracture and observed outcome variables at discharge (physical disability, complications, length of stay, and mortality) and one-year after surgery (physical disability and mortality). Results: Disability when performing instrumentalized activities of daily living (IADL) at one-year follow-up is independently related to the presence of a second hip fracture. There were no other statistically significant relationships between the presence of a second hip fracture and other observed outcome variables. Conclusions: Patients with a second hip fracture showed worse functional outcome at one-year follow-up when measured with the IADL scale. No increased short-nor long-term mortality rates were found in patients with a secondary hip fracture. IADL is a good tool to assess disability after a second hip fracture and could be thus a more reliable outcome measure when investigating differences in functional recovery in patients with a second hip fracture compared to conventionally used ADL scales.

Epidemiology and risk factors for contralateral proximal femur fracture: a single center retrospective cohort study on 1022 patients

Summary.

BACKGROUND AND AIM OF THE WORK

Given the high impact of proximal femur fractures (PFFs) on elderly patients and healthcare systems, the burden of contralateral PFFs might be overlooked. Aim of the study is to analyze the epidemiology and risk factors of contralateral proximal femur fractures. Secondary aim is to detect mortality rate differences in first and contralateral PPF.

METHODS

A population of 1022 patients admitted for proximal femur fractures in a single center was studied. Prevalence at admission as well as incidence of contralateral PFF during a 18 to 36 months follow-up was recorded. Epidemiology of contralateral PFF was studied recording number of events, time to second fracture and fracture type. Mortality at 1-year was recorded for all patients and compared between first and second PFF patients. Comorbidities, pharmacotherapy, BMI, MNA and SPMSQ were studied as possible risk factors.

RESULTS

Prevalence and incidence of contralateral PFFs were 9.4% and 6.5% respectively. Median time to second fracture was 12 months. One-year mortality of contralateral PFFs was significantly lower (20.5% vs 25.1%, p 0.003) than first PFF. Contralateral fracture patients had a significantly lower BMI and a significantly lower proportion of malnourished patients.

CONCLUSIONS

The incidence and prevalence of contralateral PFFs is relevant. Mortality of contralateral PFFs results to be lower than first PFF. Patients with higher BMI and malnourished patients have a lower risk of contralateral PFF.

Incidence of bone protection and associated fragility injuries in patients with proximal femur fractures

OBJECTIVES

Our aim was to investigate whether patients presenting with fragility fractures of the proximal femur are receiving osteoporosis treatment and to assess the number of other fragility fractures they have sustained prior to admission.

METHODS

All patients presenting to our institution with fragility fractures of the proximal femur within an 18-month period (January 2012-August 2013) were included. Patient demographics; fracture classification (AO/OTA); American Society of Anesthesiologists (ASA) grade; Abbreviated Mental Test Score (AMTS) on admission; type of operation; time to operation; peri-operative complications; length of hospital stay (LOS); walking status; osteoporotic medication; Dual-energy X-ray absorptiometry (DEXA) results; additional fragility fractures; and mortality were collected and analysed.

RESULTS

A total of 1004 patients (278 male) met the inclusion criteria and were included into the study. The mean age was 82.01 years and mean LOS was 19.54days. Fifty-four per cent of the patients were admitted from their own homes whereas 43% were capable to walk indoors without any aids before their injury. Mean time to surgery was 2.06days (Median: 1.31, range: 0-26days). Three hundred and six patients (30.5%) had at least another fragility fracture before the index episode (mean 1.40 fractures; SD: 0.71 fractures; range: 1-6 fractures). Only 16.4% were under complete osteoporosis treatment on admission, defined as receiving calcium with vitamin D and a bisphosphonate or an alternative agent. When we compared patients without a history of a previous fragility fracture (Group A) and patients with at least another previous fragility fracture (Group B), we found that patients in Group B had a significantly lower AMTS score, lower bone mineral density (BMD) as evident on the DEXA scan, an inferior mobility before admission and a higher incidence of extracapsular fractures (p<0.05). On discharge, patients in Group B had a higher chance of receiving complete bone protection compared to group A (27.9% versus 41.7%; p<0.01). Following discharge, 11.2% of the patients sustained an additional fragility fracture. The mean time from the index episode to the additional fracture was 0.65 years, whilst these injuries were more frequent in Group B (RR=1.638; p<0.05).

CONCLUSION

Patients presenting with a hip fracture are generally under-treated for osteoporosis. Post-operative assessment by a designated geriatrician and use of a standardised protocol is of paramount importance for reducing the risk of additional fragility fractures. Additionally, screening of the elderly population for identifying the patients who suffer from osteoporosis can potentially reduce the risk of sustaining a further fragility fracture.

The burden of second hip fractures: provincial surgical hospitalizations over 15 years

BACKGROUND

Second hip fractures account for up to 15% of all hip fractures. We sought to determine if the proportion of hip fracture surgeries for second hip fracture changed over time in terms of patient and fracture characteristics.

METHODS

We reviewed the records of patients older than 60 years hospitalized for hip fracture surgery between 1990 and 2005 in British Columbia. We studied the proportion of surgeries for second hip fracture among all hip fracture surgeries. Linear regression tested for trends across fiscal years for women and men.

RESULTS

We obtained 46 341 patient records. Second hip fracture accounted for 8.3% of hip fracture surgeries. For women the proportion of second hip fracture surgeries increased linearly from 4% to 13% with each age decade (p = 0.001) and across fiscal years (p = 0.002). In men the proportion of second hip fracture surgeries was 5% for each age decade between the ages of 60 and 90 years across fiscal years, increasing to 8% for men older than 90 years across fiscal years (p = 0.20). These sex-specific trends were similar for both pertrochanteric and transcervical fracture types.

CONCLUSION

Second hip fracture surgeries account for an increasing proportion of hip fracture surgeries and may require more health care resources to minimize poorer reported outcomes. Future research should determine whether more health care resources are required to manage these patients and optimize their outcomes.

One-year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil

Objective

To analyze the mortality rate at one-year follow-up of patients with hip fracture who underwent surgery at the university hospital of this institution.

Method

The authors reviewed 213 medical records of hospitalized patients aged 65 years or older, following to the order they were admitted to the orthopedics and traumatology service from January 2012 to August 2013.

Results

One-year mortality rate was 23.6%. Mortality was higher among women, with a 3:1 ratio. Anemia (p = 0.000) and dementia (p = 0.041) were significantly associated with the death group. Patients who remained hospitalized for less than 15 days and who were discharged within seven days after surgery showed increased survival.

Conclusion

In the present sample of patients with hip fracture who underwent surgery, one-year mortality rate was 23.6%, and the main comorbidities associated with this outcome were anemia and dementia.

Can radiographs of hip fractures predict subsequent hip fractures? A shape modelling analysis

INTRODUCTION

The geometrical shape of the proximal femur has previously been shown to predict primary hip fractures. Hip fractures are routinely diagnosed on plain radiographs of the pelvis, and these have both hips viewable. We have investigated if statistical shape modelling of the uninvolved hip on plain radiographs, at the time of the first hip fracture episode, could predict a subsequent 'second fracture' on that (uninvolved) side.

MATERIALS AND METHODS

60 radiographs taken at the time of the index hip fracture were blinded and separated into two arms; patients sustaining one hip fracture only (n=30), and those who went on to sustain a second fracture (n=30), over the three-year follow-up period. Two separate shape models were used for these groups and compared using t-tests or Mann-Whitney U-tests, along with Cohen's d to measure the effect size of each measure.

RESULTS

We found no statistically significant difference in the shape of the femur between the first fracture and second fracture group (p>0.05) and no results reached a "medium" effect size (Cohen's d <0.5).

CONCLUSIONS

Shape modelling is feasible and can be applied in the routine clinical setting. However, we were unable to elucidate any predictive value in this relatively small sample. A reliable radiograph-based method of identifying patients at risk of second fracture would be of value in planning prevention, service provision, and cost analysis. Further work is required and a study with more patients might exclude the type 2 error in our work.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue

OBJECTIVES

We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay.

DESIGN

Prospective consecutive series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0.

INTERVENTION

Femur, pelvis, or spine fractures treated surgically.

MAIN OUTCOME MEASUREMENTS

Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded.

RESULTS

Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days).

CONCLUSIONS

Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Costs and Complications of Short Versus Long Cephalomedullary Nailing of OTA 31-A2 Proximal Femur Fractures in U.S. Veterans

OBJECTIVES

In fractures without subtrochanteric extension, the indications for the use of short versus long cephalomedullary nails (CMNs) for intertrochanteric femur fractures are unclear. We hypothesized that long nails would be associated with higher costs and similar complication rates.

DESIGN

Retrospective comparative study.

SETTING

United States Department of Veterans Affairs Medical Centers.

PARTICIPANTS

Patients receiving CMNs for OTA 31-A2 pertrochanteric fractures from 2001 to 2010.

INTERVENTIONS

Short versus long cephalomedullary nailing.

MAIN OUTCOME MEASUREMENTS

Costs, perioperative complications, readmissions, surgical failures, and mortality.

RESULTS

We identified 262 patients with OTA 31-A2 pertrochanteric fractures (125 treated with short CMNs and 137 treated with long CMNs). The 2 cohorts had similar demographic and medical characteristics. There were no significant differences in perioperative complications, readmissions within 30 days, surgical failures within one year, or death within 30 days or one year. The average cost of hospitalization was significantly higher for the cohort treated with long nails (greater than $7000 in actual costs, and greater than $3000 when statistically adjusted for differences in postoperative lengths of stay). Multivariable analyses showed no significant differences in the rates of development of at least one complication, readmission, or death.

CONCLUSIONS

In a cohort of patients with similar characteristics and fracture patterns, the use of long CMNs was associated with similar rates of complications, readmission, and reoperations, but significantly higher costs than with the use of short nails.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Parameters Pointing at an Increased Risk for Contralateral Hip Fractures: Systematic Review

BACKGROUND

Early identification of hip fracture (HF) patients bearing an increased risk for a contralateral occurrence would allow providing preventive measures timely.

OBJECTIVES

To summarize the available evidence describing risk scores, prognostic instruments, or (groups of) parameters predicting contralateral HFs at the time point of the first fracture. Methods/Systematic Review: Articles were identified through searches in MEDLINE and Scopus from inception to April 2014, checking of reference lists of the included studies and reviews. One reviewer assessed all articles for inclusion and abstracted the data. Uncertain cases were discussed and decided with a second reviewer. Salient study and population characteristics were abstracted for each article. Studies reporting the association of a set of risk factors for second HFs were further examined and compared. The number of studies reporting on a risk parameter was assessed.

RESULTS

Searches identified 3560 records, and 47 studies were included in this review. There was a large spectrum of study designs, patient populations, and follow-up periods. Among 11 studies reporting on a set of parameters, female gender was assessed most commonly (7 times), followed by age (5) and parameters of general health, vision, and stroke (each 4 times). We were unable to depict stringent patterns of risk parameters to be used for decision making in clinical practice.

CONCLUSIONS

The findings of this article call for a conjoint effort to achieve an expert consensus regarding a critical set of parameters for a risk instrument identifying patients bearing an increased risk for contralateral HFs early.

Senior Managed Care System for Hip Fracture in the United States

Background

It is debatable whether a managed care model would affect the quality of care and length of hospital stay in the treatment of hip fractures in elderly patients.

Methods

This prospective study was undertaken to determine whether or not a managed care critical pathway tool shortened hospital stay in a group of 102 senior patients with fractures of the hip during follow-up. We compared our study findings with two equivalent populations of senior hip fracture patients not treated using a critical care pathway concerning specific markers of quality.

Results

The managed care group had a 9% mortality rate, 95% return to prefracture living and 63% return to ambulatory status. The rates compared favorably with previous studies. The quality of care provided before and after the critical pathway was equivalent, while the post-pathway length of stay dropped 30%.

Conclusions

The proposed care protocol is recommended to shorten hospital stay in elderly patients with hip fractures.

Constructing an episode of care from acute hospitalization records for studying effects of timing of hip fracture surgery

Episodes of care defined by the event of hip fracture surgery are widely used for the assessment of surgical wait times and outcomes. However, this approach does not consider nonoperative deaths, implying that survival time begins at the time of procedure. This approach makes treatment effect implicitly conditional on surviving to treatment. The purpose of this article is to describe a novel conceptual framework for constructing an episode of hip fracture care to fully evaluate the incidence of adverse events related to time after admission for hip fracture. This admission-based approach enables the assessment of the full harm of delay by including deaths while waiting for surgery, not just deaths after surgery. Some patients wait until their conditions are optimized for surgery, whereas others have to wait until surgical service becomes available. We provide definitions, linkage rules, and algorithms to capture all hip fracture patients and events other than surgery. Finally, we discuss data elements for stratifying patients according to administrative factors for delay to allow researchers and policymakers to determine who will benefit most from expedited access to surgery.

Occurrence, management and outcomes of hip fractures in patients with Parkinson's disease

INTRODUCTION

Hip fractures can be debilitating, especially in patients with pre-existing Parkinson's disease; they have reportedly worse outcomes than non-Parkinson's disease patients.

SOURCES OF DATA

A computerized literature search on PubMed, Medline, Embase, and CINAHL, supplemented by a manual search of related publications.

AREAS OF AGREEMENT

Parkinson's disease patients were found to have significantly lower bone mineral density; higher incidence of falls and hip fractures; delays to receiving their Parkinson's disease medication and surgery; higher risk of pneumonia, urinary infection, pressure sores, post-operative mortality; surgical complications and sequelae, including failed fixation, dislocation, longer hospital stay, re-operation; and increased risk of contralateral hip fracture.

AREAS OF CONTROVERSY

Regain of mobility and return to previous residential status have been variably reported.

GROWING POINTS

All Parkinson's disease patients should be screened and considered for primary prevention treatment. On admission with hip fractures, attention should be paid to avoid delays to medication, ensuring safe anaesthetic and timely surgery, and post-operative chest physiotherapy and mobilization.

RESEARCH

Research is needed in minimizing the bone-resorptive effects of anti-Parkinson's disease medication.

Excess mortality associated with second hip fracture

Hip fracture increases death risk. Ten percent of survivors have second hip fracture. It is not known if second hip fracture further increases death risk. Here, we report that second hip fracture increases death risk beyond that expected for an increase in age. Secondary prevention after hip fracture could save lives.

INTRODUCTION

The purpose of this study is to determine if second hip fracture is associated with an increased death rate.

METHODS

We retrieved 42,435 hospitalization records of patients aged 60 years or older, who were discharged after admission for hip fracture surgery between 1990 and 2005 in British Columbia, Canada. The outcome variable was the time to death.

RESULTS

During follow-up, the average monthly death rate was 16.2 (95 % CI 16.0-16.4) per 1000 patient-months for those without second hip fracture and 21.1 (95 % CI 20.2-22.1) per 1000 patient-months for those with second hip fracture. The hazard of death was 55 % higher for patients with second hip fracture compared to those without second hip fracture (HR = 1.55, 95 % CI 1.47-1.63). The hazard of death was 58 % higher for men with second hip fracture than in men without second hip fracture (HR = 1.58, 95 % CI 1.42-1.75). The hazard of death was 54 % higher for women with second hip fracture compared to women without second hip fracture (HR = 1.54, 95 % CI 1.46-1.63). These sex-specific HRs were not statistically different (p = 0.70).

CONCLUSION

Our results are the first to show that second hip fracture increases the risk of death above that anticipated for an increase in age for both men and women. Effective secondary prevention strategies could not only reduce morbidity after hip fracture but could also save lives.

Risk of second hip fracture persists for years after initial trauma

BACKGROUND

Secondary prevention often targets women who suffer from higher rates of second hip fracture than men, especially in the early years after first fracture. Yet, the occurrence of second hip fracture by certain times also depends on the death rate, which is higher in men than women. We compared the risk of sustaining second hip fracture by a certain time between women and men remaining alive at that time.

METHODS

We retrieved 38,383 hospitalization records of patients aged 60 years or older, who were discharged alive after admission for hip fracture surgery between 1990 and 2005 in British Columbia, Canada. The outcome variable was the time to a subsequent hip fracture.

RESULTS

During ten years of follow-up, 2,902 (8%) patients sustained a second hip fracture, and 21,428 (56%) died before sustaining a second hip fracture. The risk of second hip fracture in the surviving post-fracture patients was higher in women than in men: 2% vs 2%, 5% vs 4%, 9% vs 7%, 15% vs 13%, and 35% vs 30% at 1, 2, 3, 5, and 10 years after initial trauma, respectively, crude OR=1.25 (95% CI: 1.13-1.39). However, the risk did not differ between women and men after adjustment, OR=1.09 (95% CI: 0.98-1.21).

CONCLUSIONS

The risk of second hip fracture persists for at least ten years among hip fracture survivors, and therefore secondary prevention should continue beyond an early post-fracture period. Women and men have similar risks of second hip fracture and both should be considered for secondary prevention.

Achieving best practice tariff may not reflect improved survival after hip fracture treatment

Objective

The best practice tariff (BPT) incentivizes hospitals in the England and Wales National Health Service to provide multiprofessional care to patients with hip fractures. The initial six targets included: 1) admission under consultant-led joint orthopedic–geriatric care, 2) multidisciplinary assessment protocol on admission, 3) surgery within 36 hours, 4) geriatrician review within 72 hours, 5) multiprofessional rehabilitation, and 6) assessment for falls and bone protection. We aimed to examine the relationship between BPT achievement and important patient outcomes and whether the BPT could predict these independently of other validated predictors.

Materials and methods

A retrospective review was conducted on 516 patient episodes. Four outcomes were defined: 1) 30-day mortality, 2) 365-day mortality, 3) postoperative length of stay on trauma ward (LOS-T), and 4) total post-operative hospital LOS (LOS-H). Patient episodes were grouped as follows: 1) group 1, pre-BPT, 2) group 2, BPT achievers, 3) group 3, BPT fails. These were compared for mortality (χ² test) and for LOS (Kruskal–Wallis test). Event analysis was done for groups 2 and 3 using generalized linear modeling, with age, sex, American Society of Anesthesiologists grade, hemoglobin, albumin, creatinine, and BPT achievement evaluated as predictors.

Results

The three groups did not differ significantly in baseline characteristics or outcomes. In the event analysis, the risk of 30-day mortality was related only to abnormal creatinine (P=0.025); mortality at 365 days was related significantly to low albumin (P=0.023) and weakly to abnormal creatinine (P=0.089). The risks of both increased LOS-T and LOS-H were related to age only (P=0.052, P<0.001, respectively).

Conclusion

Achieving BPT does not predict any outcome of interest on its own.

The Best Practice Tariff helps improve management of neck of femur fractures: a completed audit loop

BACKGROUND

The Best Practice Tariff incentivizes hospitals in the UK to improve the care they deliver, and includes a requirement to deliver multiprofessional care to patients with neck of femur fractures. The Best Practice Tariff for 2010-11 included six targets: (1) surgery within 36 hours, (2) admission under consultant-led joint orthopaedic-geriatric care, (3) admission using a multidisciplinary assessment protocol, (4) review by a geriatrician within 72 hours, (5) geriatrician-directed multi-professional rehabilitation, and (6) assessment for falls and bone protection. The authors chose to audit their Trust's compliance with these targets.

METHODS

A retrospective audit was conducted in 2011 at the authors' university-affiliated tertiary care hospital, which is a regional major trauma centre. Only patients 65 years or older, with fragility-type neck of femur fractures who were treated surgically at the authors' unit and were eligible for geriatric review and multiprofessional rehabilitation, were included. The results of this audit (2010-11 Best Practice Tariff targets) were analysed and a series of procedural and logistical measures were introduced. A re-audit was performed in April 2012 for 2011-12, and the results for the 2 years were compared using appropriate statistics (Chi square tests and analysis of variance). Thirty-day mortality was compared using the summary hospital-level mortality indicator.

RESULTS

A total of 410 patients were eligible for Best Practice Tariff in 2010-11, which increased to 463 in 2011-12. The changes from the first year's audit helped increase the rates for 36-hour surgery from 48.3% to 73.4% and for 72-hour geriatric review from 68.8% to 81.8% (P<0.05). The annual Best Practice Tariff achievement increased from 31.7% to 61.3% (P<0.05). The summary hospital-level mortality indicator declined from 96.5 to 61.3.

CONCLUSIONS

Focusing on poorly satisfied Best Practice Tariff indicators can produce a significant improvement in the per capita Best Practice Tariff achievement. Further studies are needed to assess the health and financial gain in detail.