Baseline and pre-operative 1-year mortality risk factors in a cohort of 509 hip fracture patients consecutively admitted to a co-managed orthogeriatric unit (FONDA Cohort)
Introduction
Fragility hip fracture, with 620,000 new cases per year in the European Union in 2010 and more than 210,000 new cases per year in the US between 2008 and 2011 [[1], [2]], is a public health problem because of its high frequency and impact on older patients. For reasons not yet fully understood, 1-year mortality after a hip fracture varies between 12.1% and 35% [[3], [4], [5], [6], [7], [8], [9], [10], [11], [12]], which signifies an excess of mortality of 8% to 18% per year compared to the population of the same age without hip fracture [13].
In terms of health care, considerable advances in surgery and anaesthesia have been made in recent decades, and different care models for patients with hip fracture have also been developed. These range from care provided by orthopaedic surgeons in orthopaedic wards, with or without the support of a geriatric consultant team, to acute orthogeriatric units, where patients are admitted from the emergency department to a unit with shared care or co-managed by both specialties. Evidence suggests that the latter model provides better acute and long-term care, resulting in shorter hospital stay and a lower mortality rate [[14], [15], [16], [17], [18]]. For this reason, from now on we shall refer mainly to studies conducted in these co-managed units.
Several studies have analysed the patient characteristics associated with a greater risk of 1-year mortality after a hip fracture. These include demographic factors, such as age and male sex [[3], [4], [6], [7], [8], [11]]; orthopaedic factors, such as fracture type [[3], [4]]; prior functional status, such as impaired mobility and dependence for basic or instrumental activities of daily living [[3], [4], [6], [7], [8], [9], [11]]; mental problems, such as the presence of cognitive impairment or dementia [[3], [4], [7], [8]]; clinical factors, such as the number of comorbidities [[3], [4], [6], [7], [9], [11]]; malnutrition [[11], [19]]; the presence of certain diseases, such as cancer [4], heart disease [[4], [20]], kidney failure [[4], [21]], anaemia [[4], [21], [22]], chronic obstructive pulmonary disease (COPD) [4], diabetes [4], hyperparathyroidism [21] or postoperative complications [23]; laboratory abnormalities, such as hypoalbuminaemia [[4], [9], [12], [21]] or lymphopenia [21]; care factors, such as delayed surgery [[5], [7], [20], [24], [25]]; and social factors, such as living in residential care [[3], [4], [23]].
While it would be interesting to determine the influence of all these factors together, most studies [[5], [12], [20], [21], [22], [24], [25]] have only partially analysed these patients, focussing on certain types of variable (functional, clinical or analytical) without making a comprehensive assessment. Others have excluded hip fracture patients with dementia, living in residential care [19], or non-surgical patients [26], while others, in contrast, restrict their series to patients living in residential care [27], or analyse only small series of patients [[9], [20], [26], [27]]. We were unable to find studies that include features now considered important in the older population, such as muscle strength and sarcopenia. The aim of this study, therefore, was to determine the patient characteristics that predict 1-year mortality after hip fracture. To do this, we conducted a comprehensive geriatric assessment and evaluated other variables currently considered relevant in this patient population in a representative cohort of patients admitted consecutively over the course of 1 year to a unit co-managed by Orthopaedic Surgery and Geriatric Medicine using a protocol designed to minimize the consequences of the hip fracture.
The study was approved by the Independent Ethics Committee of Hospital Universitario La Paz (Reference HULP-PI-1334). An informed consent form was obtained from patients or relatives before inclusion in the study.
Section snippets
Methods
Setting and subjects
All patients aged over 65 years diagnosed with fragility hip fracture and admitted consecutively to a 1300-bed public university hospital from 25 January 2013 to 24 February 2014 (FONDA cohort) were included. This hospital is the only reference centre for geriatric hip fracture in a health district with a population of about 520,000 (Northern Madrid Health District, Spain).
Patients were admitted directly from the Emergency Service to the Orthogeriatric Unit co-managed by the
Results
A total of 509 patients with a mean age of 85.6 ± 6.9 years were hospitalized during the study period. Of these, 403 (79.2%) were women and 116 patients (22.8%) came from residential care. Extracapsular hip fracture was recorded in 295 (58%) cases and 491 patients (96.5%) underwent surgery, consisting of osteosynthesis with intramedullary nail in 268 (54.7%) cases, prosthesis implantation in 184 (37.6%), and other techniques in 39 (7.8%) patients. Twenty-one patients (4.1%) died in hospital.
Discussion
In this study, we analysed the factors associated with mortality at 12 months of suffering a hip fracture in 509 consecutive patients treated in an orthogeriatric unit who had undergone comprehensive evaluation, including clinical, functional, mental, body-composition and analytical variables. Eight independent factors (age, baseline functional status according to the Barthel Index, cognitive impairment, low BMI, cardiac disease, low hand-grip strength, presence of anaemia at admission, and
Conflicts of interest
All authors declare that they have no conflict of interest.
Acknowledgements
The study was supported in part by a grant (Grant to Emerging Research Groups 2012) from the Instituto de Investigación Biomédica del Hospital Universitario La Paz, Madrid, Spain (IdiPAZ) (FONDA Cohort Study, PI-1334 Project) and a grant from the ISCIII Fondos FEDER (RETICEF RD 06/0013/1013 and RD12/0043/0019).
References (40)
- et al.
Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States
Mayo Clin Proc
(2015) - et al.
Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis
Injury
(2012) - et al.
Time to surgery and rehabilitation resources affect outcomes in orthogeriatric units
Arch Gerontol Geriatr
(2012) - et al.
Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year
Injury
(2008) - et al.
Routine blood tests as predictors of mortality in hip fracture patients
Injury
(2012) - et al.
The Spanish versions of the Barthel index (BI) and the Katz index (KI) of activities of daily living (ADL): A structured review
Arch Gerontol Geriatr
(2009) - et al.
Estimation of stature by measuring fibula and ulna bone length in 2443 older adults
J Nutr Health Aging
(2009) - et al.
Hand grip strength: outcome predictor and marker of nutritional status
Clin Nutr
(2011) - et al.
Predicting 30-day mortality following hip fracture surgery: evaluation of six risk prediction models
Injury
(2015) - et al.
Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA)
Arch Osteoporos
(2013)
Pre-operative indicators for mortality following hip fracture surgery: a systematic review and meta-analysis
Age Ageing
Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression
Can J Anesth Can d’ anesthésie
The 1-Year mortality of patients treated in a hip fracture program for elders
Geriatr Orthop Surg Rehabil
Predictors of mortality after hip fracture: results from 1-year follow-up
Aging Clin Exp Res
Dedicated orthogeriatric service reduces hip fracture mortality
Irish J Med Sci (1971)
Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment
Osteoporos Int
Preoperative albumin as a predictor of one-year mortality in patients with fractured neck of femur
Ann R Coll Surg Engl
Meta-analysis: excess mortality after hip fracture among older women and men
Ann Intern Med
Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis
J Orthop Trauma
Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study
Age Ageing
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