Elsevier

Injury

Volume 49, Issue 3, March 2018, Pages 656-661
Injury

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)

https://doi.org/10.1016/j.injury.2018.01.003Get rights and content

Abstract

Introduction

The aim of this study was to determine the patient characteristics that predict 1-year mortality after a hip fracture (HF).

Methods

All patients admitted consecutively with fragility HF during 1 year in a co-managed orthogeriatric unit of a university hospital (FONDA cohort) were assesed. Baseline and admission demographic, clinical, functional, analytical and body-composition variables were collected in the first 72 h after admission. A protocol designed to minimize the consequences of the HF was applied. One year after the fracture patients or their carers were contacted by telephone to ascertain their vital status.

Results

A total of 509 patients with a mean age of 85.6 years were included. One-year mortality was 23.2%. The final multivariate model included 8 independent mortality risk factors: age >85 years, baseline functional impairment in basic activities of daily living, low body mass index, cognitive impairment, heart disease, low hand-grip strength, anaemia at admission, and secondary hyperparathyroidism associated with vitamin D deficiency. The association of several of these factors greatly increased mortality risk, with an OR (95% confidence interval [CI]) of 5.372 (3.227–8.806) in patients with 4 to 5 factors, and an OR (95% CI) of 11.097 (6.432–19.144) in those with 6 or more factors.

Conclusions

In addition to previously known factors (such as age, impairment in basic activities of daily living, cognitive impairment, malnutrition and anaemia at admission), other factors, such as muscle strength and hyperparathyroidism associated with vitamin D deficiency, are associated with greater 1-year mortality after a HF.

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).

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