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Patel R, Judge A, Johansen A, Marques EMR, Chesser T, Griffin XL, Javaid MK, Ben-Shlomo Y, Gregson CL. Patients' recovery of mobility and return to original residence after hip fracture are associated with multiple modifiable components of hospital service organisation: the REDUCE record-linkage cohort study in England and Wales. BMC Geriatr 2023; 23:459. [PMID: 37501122 PMCID: PMC10375618 DOI: 10.1186/s12877-023-04038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/12/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Hip fractures are devastating injuries causing disability, dependence, and institutionalisation, yet hospital care is highly variable. This study aimed to determine hospital organisational factors associated with recovery of mobility and change in patient residence after hip fracture. METHODS A cohort of patients aged 60 + years in England and Wales, who sustained a hip fracture from 2016 to 2019 was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality records were linked to 101 factors derived from 18 hospital-level organisational metrics. After adjustment for patient case-mix, multilevel models were used to identify organisational factors associated with patient residence at discharge, and mobility and residence at 120 days after hip fracture. RESULTS Across 172 hospitals, 165,350 patients survived to discharge, of whom 163,230 (99%) had post-hospital discharge destination recorded. 18,323 (11%) died within 120 days. Among 147,027 survivors, 58,344 (40%) across 143 hospitals had their residence recorded, and 56,959 (39%) across 140 hospitals had their mobility recorded, at 120 days. Nineteen organisational factors independently predicted residence on hospital discharge e.g., return to original residence was 31% (95% confidence interval, CI:17-43%) more likely if the anaesthetic lead for hip fracture had time allocated in their job plan, and 8-13% more likely if hip fracture service clinical governance meetings were attended by an orthopaedic surgeon, physiotherapist or anaesthetist. Seven organisational factors independently predicted residence at 120 days. Patients returning to their pre-fracture residence was 26% (95%CI:4-42%) more likely if hospitals had a dedicated hip fracture ward, and 20% (95%CI:8-30%) more likely if treatment plans were proactively discussed with patients and families on admission. Seventeen organisational factors predicted mobility at 120 days. More patients re-attained their pre-fracture mobility in hospitals where (i) care involved an orthogeriatrician (15% [95%CI:1-28%] improvement), (ii) general anaesthesia was usually accompanied by a nerve block (7% [95%CI:1-12%], and (iii) bedside haemoglobin testing was routine in theatre recovery (13% [95%CI:6-20%]). CONCLUSIONS Multiple, potentially modifiable, organisational factors are associated with patient outcomes up to 120 days after a hip fracture, these factors if causal should be targeted by service improvement initiatives to reduce variability, improve hospital hip fracture care, and maximise patient independence.
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Affiliation(s)
- Rita Patel
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Antony Johansen
- School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, UK
- National Hip Fracture Database, Royal College of Physicians, London, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Tim Chesser
- Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Xavier L Griffin
- Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research (NIHR) Applied Research Collaboration West (ARC West) at University of Bristol and United Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.
- Older People's Unit, Royal United Hospital NHS Foundation Trust Bath, Combe Park, Bath, UK.
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Harman H, Walton TJ, Chan G, Stott P, Ricketts DM, Rogers BA. Predicting 30-day mortality after hip fracture: the G4A calibrated prognostic tool. Hip Int 2022; 32:820-825. [PMID: 33755498 DOI: 10.1177/1120700021998959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. MATERIALS AND METHODS We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters' relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. RESULTS The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow 'goodness of fit' test showed good concordance between observed and predicted mortality rates. CONCLUSIONS We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.
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Affiliation(s)
- Holly Harman
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Thomas J Walton
- Trauma and Orthopaedic Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Gareth Chan
- Trauma and Orthopaedic Department, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - Philip Stott
- Trauma and Orthopaedic Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - David M Ricketts
- Trauma and Orthopaedic Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Benedict A Rogers
- Trauma and Orthopaedic Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Chan G, Narang A, Aframian A, Ali Z, Bridgeman J, Carr A, Chapman L, Goodier H, Morgan C, Park C, Sexton S, Sugand K, Walton T, Wilson M, Belgaumkar A, Gallagher K, Ghosh K, Gibbons C, Jacob J, Keightley A, Nawaz Z, Sarraf K, Wakeling C, Kieffer W, Rogers B. Medium-term mortality after hip fractures and COVID-19: A prospective multi-centre UK study. Chin J Traumatol 2022; 25:161-165. [PMID: 34794857 PMCID: PMC8555117 DOI: 10.1016/j.cjtee.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/18/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The COVID-19 pandemic has caused 1.4 million deaths globally and is associated with a 3-4 times increase in 30-day mortality after a fragility hip fracture with concurrent COVID-19 infection. Typically, death from COVID-19 infection occurs between 15 and 22 days after the onset of symptoms, but this period can extend up to 8 weeks. This study aimed to assess the impact of concurrent COVID-19 infection on 120-day mortality after a fragility hip fracture. METHODS A multi-centre prospective study across 10 hospitals treating 8% of the annual burden of hip fractures in England between 1st March and 30th April, 2020 was performed. Patients whose surgical treatment was payable through the National Health Service Best Practice Tariff mechanism for "fragility hip fractures" were included in the study. Patients' 120-day mortality was assessed relative to their peri-operative COVID-19 status. Statistical analysis was performed using SPSS version 27. RESULTS A total of 746 patients were included in this study, of which 87 (11.7%) were COVID-19 positive. Mortality rates at 30- and 120-day were significantly higher for COVID-19 positive patients relative to COVID-19 negative patients (p < 0.001). However, mortality rates between 31 and 120-day were not significantly different (p = 0.107), 16.1% and 9.4% respectively for COVID-19 positive and negative patients, odds ratio 1.855 (95% CI 0.865-3.978). CONCLUSION Hip fracture patients with concurrent COVID-19 infection, provided that they are alive at day-31 after injury, have no significant difference in 120-day mortality. Despite the growing awareness and concern of "long-COVID" and its widespread prevalence, this does not appear to increase medium-term mortality rates after a hip fracture.
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Affiliation(s)
- Gareth Chan
- Brighton & Sussex University Hospitals NHS Trust, Brighton & Sussex Medical School, Falmer Campus, Brighton, UK,Corresponding author.
| | - Ashish Narang
- Surrey & Sussex Healthcare NHS Trust, Canada Avenue, Redhill, UK
| | - Arash Aframian
- Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Zaid Ali
- Surrey & Sussex Healthcare NHS Trust, Canada Avenue, Redhill, UK
| | - Joseph Bridgeman
- Ashford & St. Peter's Hospital NHS Foundation Trust, Chertsey, UK
| | - Alastair Carr
- Surrey & Sussex Healthcare NHS Trust, Canada Avenue, Redhill, UK
| | - Laura Chapman
- Western Sussex Hospitals NHS Foundation Trust (St. Richard's Hospital), Chichester, UK
| | - Henry Goodier
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - Catrin Morgan
- Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Chang Park
- Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Sexton
- Western Sussex Hospitals NHS Foundation Trust (St. Richard's Hospital), Chichester, UK
| | - Kapil Sugand
- Imperial College Healthcare NHS Trust, London, UK
| | - Thomas Walton
- Brighton & Sussex University Hospitals NHS Trust, Brighton & Sussex Medical School, Falmer Campus, Brighton, UK
| | - Michael Wilson
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - Ajay Belgaumkar
- Surrey & Sussex Healthcare NHS Trust, Canada Avenue, Redhill, UK
| | - Kieran Gallagher
- Poole General Hospital & the Royal Bournemouth Hospital, Poole, UK
| | - Koushik Ghosh
- Western Sussex Hospitals NHS Foundation Trust (Worthing Hospital), Worthing, UK
| | - Charles Gibbons
- Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
| | - Joshua Jacob
- Ashford & St. Peter's Hospital NHS Foundation Trust, Chertsey, UK
| | | | - Zuhair Nawaz
- Frimley Health NHS Foundation Trust, Frimley, UK
| | | | - Christopher Wakeling
- Western Sussex Hospitals NHS Foundation Trust (St. Richard's Hospital), Chichester, UK
| | - William Kieffer
- Surrey & Sussex Healthcare NHS Trust, Canada Avenue, Redhill, UK
| | - Benedict Rogers
- Brighton & Sussex University Hospitals NHS Trust, Brighton & Sussex Medical School, Falmer Campus, Brighton, UK
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Nanchappan NS, Chopra S, Samuel A, Therumurtei L, Ganapathy SS. Mortality Rate and Ten Years Survival of Elderly Patients Treated with Total Hip Arthroplasty for Femoral Neck Fractures. Malays Orthop J 2021; 15:136-142. [PMID: 34429834 PMCID: PMC8381664 DOI: 10.5704/moj.2107.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/19/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Mortality following traumatic femoral neck fractures in the elderly (age >60 years) is influenced by many factors. Addressing some of them may reduce the mortality rate thus improving patient survival and quality of life. Materials and methods: This study was a retrospective research using data collected from Hospital Sultanah Bahiyah, Kedah between the years 2008-2018. We measured outcomes such as age, gender, hospital stay, default rate, ambulation post-surgery, American Society of Anaesthesiologists score (ASA) and surgical timing in correlation with mortality rate and 10-year survival of elderly patients treated with Total Hip Arthroplasty for femoral neck fractures in this centre. Results: A total of 291 traumatic femoral neck fractures aged above 60 years post total hip arthroplasty performed were included. There was higher number of female (n =233) compared to male (n=53) Estimated 10 years survival from Kaplan Meier was 42.88% (95% CI: 33.15, 52.54). One year mortality rate in our study was found to be 18.9%. The average time to event was 7.1 years (95% CI:33.15, 52.24) with a mean age group of 75. Discussion: Total hip arthroplasty patients not ambulating after surgery had a 4.2 times higher hazard ratio compared to ambulators. Those with pre-existing systemic disease (ASA III and IV) were found to have the highest hazard ratio, almost five times that of healthy patients, after adjusting for confounding factors. Delay of more than seven days to surgery was found to be a significant factor in 10-year survival with a hazard ratio of 3.8, compared to surgery performed earlier. Conclusion: Delay of more than 7 days to surgery in 10 years survival was significant with high hazard ratio. It is a predictor factor for survival in 10 years. A larger sample size with a prospective design is required to confirm our findings regarding “unacceptable surgical timing” for femoral neck fractures in patients above 60 years of age.
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Affiliation(s)
- N S Nanchappan
- Department of Orthopaedics, Hospital Sultanah Bahiyah, Alor Setar, Malaysia
| | - S Chopra
- Department of Orthopaedics, Hospital Sultanah Bahiyah, Alor Setar, Malaysia
| | - A Samuel
- Department of Orthopaedics, Hospital Sultanah Bahiyah, Alor Setar, Malaysia
| | - L Therumurtei
- Department of Orthopaedics, Hospital Sultanah Bahiyah, Alor Setar, Malaysia
| | - S S Ganapathy
- Institute for Public Health, National Institutes of Health, Shah Alam, Malaysia
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Moore P, An VVG, Nandapalan H, Sivakumar B. Dedicated hip fracture services: A systematic review. ANZ J Surg 2021; 91:2163-2166. [PMID: 34085394 DOI: 10.1111/ans.16989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hip fractures (HFs) are common and pose a significant burden to both the individual and the community. Prompt operative management and aggressive rehabilitation have been shown to improve outcomes. However, there is often a delay in treatment due to lack of theatre availability and appropriate perioperative multi-disciplinary care. This study reviews the literature and reports on outcomes of HFs treated in dedicated units with allocated theatre time and pre-determined multi-disciplinary perioperative pathways. It also provides comparison against outcomes data from HF registries, both domestically and internationally. METHODS An electronic literature search was performed to identify original, English language studies reporting on patient outcomes from dedicated HF units (HFUs). Studies were graded using the Journal of Bone and Joint Surgery criteria. Data were extracted from the text, table and figures of the selected studies. RESULTS Five appropriate studies, with a total cohort of 6633 patients (4032 of whom were treated in a dedicated HFU), were identified. Patients treated in these units sustained a lower mortality rate (Risk Ratio = 0.62, p = 0.01). CONCLUSIONS This review demonstrates that centres with dedicated HFUs result in improved 30-day mortality. Further research may demonstrate more sustained improvements in outcomes. The implementation of dedicated HFUs within health systems should be considered.
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Affiliation(s)
- Parisse Moore
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Hornsby, New South Wales, Australia
| | - Vincent V G An
- Department of Orthopaedic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Haren Nandapalan
- Department of Orthopaedic Surgery, Hawkesbury Hospital, Windsor, New South Wales, Australia
| | - Brahman Sivakumar
- Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Hornsby, New South Wales, Australia
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Oputa TJ, Dupley L, Bourne JT. One Hundred Twenty-Day Mortality Rates for Hip Fracture Patients with COVID-19 Infection. Clin Orthop Surg 2021; 13:135-143. [PMID: 34094003 PMCID: PMC8173233 DOI: 10.4055/cios20286] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/27/2021] [Accepted: 03/01/2021] [Indexed: 12/18/2022] Open
Abstract
Background Increased 30-day mortality rates have been reported for patients with hip fractures and a concurrent diagnosis of coronavirus disease 19 (COVID-19) infection. Due to nosocomial spread of infection and the variable incubation period with the virus, follow-up past 30 days after injury is required to evaluate the true mortality amongst these patients. We aim to assess 120-day mortality rates in hip fracture patients with COVID-19 infection and compare this to hip fracture patients without COVID-19 infection presenting during the same time period. Methods This is a retrospective multicenter review of all patients aged ≥ 60 years admitted with a fractured neck of femur between March 5 and April 5, 2020, at nine U.K. trauma units. COVID-19 status, demographic data, comorbidities, and date of death (if applicable) were collected. Results Data were collected for 265 hip fracture patients. Forty-six patients (17.4%) tested positive for COVID-19 infection. There were no significant differences in age or Charlson comorbidity score between those with or without COVID-19. Those with COVID-19 infection were more likely to be male (p = 0.01). Patients with COVID-19 had a 30-day mortality of 35% versus 10% in patients without (p < 0.01). One hundred twenty-day mortality was also greater in those with COVID-19 infection at 63% compared to those without at 17% (p < 0.01). Previous history of myocardial infarction was the only independent factor that showed to increase mortality rate (p = 0.03). Subgroup analysis also revealed significantly increased mortality rates at 120 days in men (27% vs. 67%), women (14% vs. 59%), and those undergoing surgery (56% vs. 30%). Conclusions We report a significantly increased mortality rate at 30 and 120 days after injury in an already high-risk cohort of surgical patients. With nearly half of patients being diagnosed with COVID-19 at 14 days or greater following admission, this study highlights the importance of taking appropriate measures to decrease the incidence of nosocomial infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in hip fracture patients.
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Affiliation(s)
- Tobenna J Oputa
- Department of Trauma and Orthopaedics, Health Education North West, Manchester, UK
| | - Leanne Dupley
- Department of Trauma and Orthopaedics, Health Education North West, Manchester, UK
| | - James T Bourne
- Lancashire Teaching Hospitals, Royal Preston Hospital, Preston, UK
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