The Association Between Socioeconomic Position and Infection Risk After Hip Fracture Surgery: A Nationwide Cohort Study of 54,853 Patients

To investigate whether socioeconomic inequalities in infection risk after hip fracture changed between 2010 and 2021. Using Danish population-based registries, we identified 74,068 patients with hip fracture. We collected data on socioeconomic position markers (education, liquid assets, marital status, and living arrangements) to examine their effect on risk of post-surgical infection. We studied any hospital-treated infection or community-treated infection occurring within 30 days after surgery during four calendar periods. We computed the cumulative incidences of infections. We measured inequality over time by estimating the adjusted slope index of inequality (SII), a hazard difference of infection/100 person years, using additive hazard regression and adjusted relative index of inequality (RII), a relative hazard, using Cox proportional hazard regression. We calculated 95% confidence intervals for all estimates. The incidence of hospital-treated infections (in total 12,654 patients) ranged between 14 and 21% and that of community-treated infections (in total 20,523 patients) ranged between 21 and 38% depending on calendar period and socioeconomic position. During 2010-2021, inequality in hospital-treated infections increased according to education (SII 14 [- 20; 49] and RII 1.1 [0.9; 1.3] in 2010 vs. SII 36 [0; 71] and RII 1.2 [1; 1.3] in 2021) and marital status (SII 29 [- 9; 66] and RII 1.2 [1; 1.4] in 2010 vs. SII 84 [45; 123] and RII 1.4 [1.2; 1.7] in 2021). Similar trends were observed for community-treated infections. Inequality in hospital-treated infection increased according to living arrangements (SII - 32 [- 78; 14] and RII 0.9 [0.7; 1.1] in 2010 vs. SSI 106 [59; 153] and RII 1.5 [1.3; 1.8] in 2021), whereas inequality according to liquid assets remained unchanged over time for both outcomes. Our results indicate growing inequality in health among patients with hip fracture, whereby lower education, lack of social support, and reliance on residential care represent increasing disadvantages for infection risk. This gap may have implications for infection prevention and treatment.

ABSTRACTBackgroundChronic opioid use is a common and serious consequence of hip fracture. We examined the association between socioeconomic position (SEP) and chronic opioid use after hip fracture surgery.MethodsUsing nationwide Danish registries, we included patients aged ≥ 65 years undergoing hip fracture surgery in 2012–2021 (n = 52,801). Cohabitation, liquid assets, and education were markers of SEP. Chronic opioid use was defined as ≥ 2 prescriptions of opioids 31–365 days post‐surgery. For the same period, all opioid doses were converted to morphine milligram equivalents (MME), mg/day. We used log‐binomial regression to estimate adjusted risk ratios (aRR) with 95%‐confidence intervals (CI) comparing patients within each SEP marker, adjusting for relevant confounding.ResultsThe 1‐year risks of chronic opioid use were 33% for patients living alone versus 30% for patients cohabiting (aRR 1.05 [CI 1.02–1.09]), 37% for low versus 28% for high levels of liquid assets (aRR 1.28 [CI 1.23–1.34]), and 33% for low versus 28% for high education (aRR 1.19 [CI 1.14–1.25]). Patients living alone used 11.5 MME mg/day versus 9.8 mg/day in patients cohabiting, patients with low liquid assets used 14.8 versus 7.9 mg/day in patients with high liquid assets, and patients with low education used 11.8 versus 7.9 mg/day in patients with high education.ConclusionsAbout a third of hip fracture patients are using opioids continuously in the year after surgery. Living alone, less liquid assets, and low education were associated with a higher risk of opioid use and dosage of use, both in preoperative opioid users and non‐users.Significance StatementThis study shows that among patients undergoing hip fracture surgery, low socioeconomic position measured by living alone, having less liquid assets or low education is associated with a higher risk of chronic opioid use and higher dosage of use in the first year postoperatively. Clinicians should consider socioeconomic position when prescribing opioids after hip fracture. The integration of less addictive opioids and non‐pharmacological approaches in the pain management may reduce opioid use and improve patient safety.

BackgroundThe loss of pre-fracture basic mobility status is associated with increased mortality and any readmission after hip fracture. However, it is less known if the loss of pre-fracture mobility has impact on acquiring a post-discharge infection. PurposeTo examine if the loss of pre-fracture basic mobility status at hospital discharge was associated with hospital-treated or community-treated infections within 30-days of hospital discharge after hip fracture. MethodsUsing the nationwide Danish Multidisciplinary Hip Fracture Registry from January 2014 through November 2017, we included 23,309 patients undergoing surgery for a first-time hip fracture. The Cumulated Ambulation Score (CAS, 0-6 points) was recorded using questionnaire at admission (pre-fracture CAS) and objectively assessed at discharge. The loss of any CAS-points at discharge compared with pre-fracture CAS was calculated and dichotomized (yes/no). Using Cox regression analyses, we estimated the hazard ratio (HR) with 95% confidence interval (CI) of any hospital-treated infection, hospital-treated pneumonia or community-treated infection adjusted for sex, age, body mass index, Charlson Comorbidity Index, residential status, type of fracture, and length of hospital stay (LOS). ResultsTotal of 12,046 (62%) patients lost their pre-fracture CAS status at discharge. Among patients who had lost their pre-fracture CAS, 6.0% developed a hospital-treated infection compared to 4% of those who did not lose their pre-fracture CAS. Correspondingly, 9.2% versus 6.2% developed a community-treated infection. The risk of 30-day post-discharge infection increased with increasing loss of any CAS points. The adjusted HRs for patients who had lost their pre-fracture CAS status, compared to patients who did not, was 1.34 (CI: 1.16-1.54) for hospital-treated infection, 1.35 (CI: 1.09 – 1.67) for pneumonia and 1.36 (CI: 1.21-1.52) for community-treated infection. ConclusionIn this large national cohort study, we found that loss of pre-fracture basic mobility status upon hospital discharge was strongly associated with 30-day post-discharge risk of developing infection. These findings suggest a clinical importance of carefully focusing on regaining the pre-fracture basic mobility before discharging the patient.

SummaryImpact of comorbidity on infection risk among hip fracture patients is unclear. We found high incidence of infection. Comorbidity was an important risk factor for infection up to 1 year after surgery. Results indicates a need for additional investment in pre- and postoperative programs that assist patients with high comorbidity.PurposeComorbidity level and incidence of infection have increased among older patients with hip fracture. The impact of comorbidity on infection risk is unclear. We conducted a cohort study examining the absolute and relative risks of infection in relation to comorbidity level among hip fracture patients.MethodsUtilizing Danish population-based medical registries, we identified 92,600 patients aged ≥ 65 years undergoing hip fracture surgery between 2004 and 2018. Comorbidity was categorized by Charlson comorbidity index scores (CCI): none (CCI = 0), moderate (CCI = 1–2), or severe (CCI ≥ 3). Primary outcome was any hospital-treated infection. Secondary outcomes were hospital-treated pneumonia, urinary tract infection, sepsis, reoperation due to surgical-site infection (SSI), and a composite of any hospital- or community-treated infection. We calculated cumulative incidence and hazard ratios (aHRs) adjusted for age, sex, and surgery year, including 95% confidence intervals (CIs).ResultsPrevalence of moderate and severe comorbidity was 40% and 19%, respectively. Incidence of any hospital-treated infection increased with comorbidity level within 0–30 days (none 13% vs. severe 20%) and 0–365 days (none 22% vs. 37% severe). Patients with moderate and severe comorbidity, compared to no comorbidity, had aHRs of 1.3 (CI: 1.3–1.4) and 1.6 (CI: 1.5–1.7) within 0–30 days, and 1.4 (CI: 1.4–1.5) and 1.9 (CI: 1.9–2.0) within 0–365, respectively. Highest incidence was observed for any hospital- or community-treated infection (severe 72%) within 0–365 days. Highest aHR was observed for sepsis within 0–365 days (severe vs. none: 2.7 (CI: 2.4–2.9)).ConclusionComorbidity is an important risk factor for infection up to 1 year after hip fracture surgery.

Incidence and risk factors for hip or other bone fractures among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study

Cardiovascular diseases are often screened using the 12-lead electrocardiogram utilizing signal processing techniques based on preconfigured parameters.To improve prediction, deep neural networks were employed in which the raw signal was evaluated without interpretation based on pre-existing electrocardiogram knowledge.A model to predict the patient's age from the raw electrocardiogram signal using a large population-based cohort (more than 1.5 million subjects; CODE cohort) was constructed.The model was evaluated using three additional large cohorts.The primary outcome was the risk of death based on the difference between the electrocardiogram predicted and the subject's actual chronological age.An estimated electrocardiogram age of more than 8 yr over the chronological age significantly predicted mortality (hazard ratio, 1.79 [95% CI, 1.69 to 1.90]; P < 0.001).Patients with an electrocardiogram age less than 8 yr over chronological age had lower risk of death (hazard ratio, 0.78 [95% CI, 0.74 to 0.83]; P < 0.001).Cardiovascular risk factors (hypertension, diabetes, and smoking) were associated with a predicted electrocardiogram age of more than 8 yr.Reviews by three cardiologists were unable to discriminate between higher electrocardiogram predicted age; analysis suggests that low-frequency components (P and T waves, components between 8 and 15 Hz) were most likely to contribute to model prediction.(Article Selection: Beatrice Beck-Schimmer, M.D. Image:

Delirium is a common complication following hip fracture surgery. We introduced a peri-operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p=0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1-4.4) (p=0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30days postoperatively) including: all-cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p<0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p<0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p=0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.

We aimed to examine trends in the incidence of treated infections following hip fracture surgery in Denmark from 2005 to 2016. We conducted a nationwide cohort study using individual-level linked data from Danish population-based registries. We calculated cumulative incidence considering death as competing risk and, based on the pseudo-observation method, risk ratios (RRs) with 95% confidence interval (CI) using the period 2005-2006 as a reference. RRs were adjusted for age, sex, and comorbidity. A total of 74,771 patients aged 65 years or older with first-time hip fracture surgery were included. The risk of postoperative (at 15, 30, 90, and 365 days) infections increased during 2005-2016. The 30-day cumulative incidence of all hospital-treated infections increased from 10.8% (95% CI, 10.2% to 11.3%) in 2005-2006 to 14.3% (95% CI, 13.7% to 15.0%) in 2015-2016 (adjusted RR 1.32; 95% CI, 1.23 to 1.42). Adjusted RR for 30-day hospital-treated pneumonia was 1.70 (95% CI, 1.49 to 1.92). The 30-day cumulative incidence of redeeming community-based antibiotic prescriptions increased from 17.5% (95% CI, 16.8% to 18.2%) in 2005-2006 to 27.1% (95% CI, 26.3% to 27.9%) in 2015-2016 (adjusted RR 1.54; 95% CI, 1.47 to 1.62). The largest increase was observed for broad-spectrum antibiotic use (adjusted RR 1.79; 95% CI, 1.68 to 1.90). During 2005-2016, risk of infections was substantially higher in hip fracture patients than in the general population. The risk of hospital-treated pneumonia and antibiotic prescriptions increased more over time among hip fracture patients. We found increased risks of postoperative treated infections following hip fracture surgery during the 12-year study period, which could not entirely be explained by similar infection trends in the general population. Given the high mortality following infections in the elderly, further research is needed to identify patients at increased risk to target preventive treatment and potentially reduce complications and mortality in hip fracture patients. © 2018 American Society for Bone and Mineral Research.

Key summary pointsAimTo examine the association between early mobilization after hip fracture surgery and the risk of long-term opioid therapy at 1-year follow-up.FindingsLong-term opioid therapy is a common complication after hip fracture surgery.Mobilization within 24 h after surgery is associated with a lower risk of long-term opioid therapy compared to mobilization between 24 and 36 h.MessageEarly mobilization is one of the key elements of the successful patient recovery for reducing risk of complications and mortality after hip fracture surgery.PurposeEarly mobilization after hip fracture operation is associated with better clinical outcomes, but its impact on long-term opioid therapy (LTOT) remains unclear.MethodsUsing Danish population-based registries we included patients aged ≥ 65 who underwent surgery for a first-time hip fracture between 2016 and 2021 (n = 36,229). LTOT was defined as redeeming ≥ 2 prescriptions between 31 and 365 days of surgery. Using stabilized inverse probability of treatment (sIPT) weighing, we calculated risks and risk differences with 95% confidence intervals (CI) for opioid use balancing mobilization groups ≤ 24 h vs 24–36 h on measured confounders and taking death into consideration.Results67.3% of all patients were women and the median age was 82.6 years (75.8; 88.6). 75% of patients were mobilized ≤ 24 h of surgery, whereas 8% were mobilized between 24 and 36 h, 4.9% > 36 h, and 12.1% had missing data on mobilization. Patients mobilized ≤ 24 h and 24–36 h were similar in age, fracture type, and marital status, but those mobilized ≤ 24 h had fewer comorbidities, better pre-fracture mobility, and a higher social position. They also had a lower risk of LTOT (29.99%) compared to those mobilized 24–36 h (33.42%), with a weighted risk difference of 3.44% (95% CI 1.58–5.30).ConclusionsLTOT is common after hip fracture surgery. Mobilization ≤ 24 h after surgery is associated with a lower risk of LTOT compared to mobilization between 24 and 36 h. Early mobilization is one of the key elements of successful patient recovery for reducing complications and mortality after hip fracture surgery.

IntroductionArthropod-borne viruses (arboviruses) are of notable public health importance worldwide, owing to their potential to cause explosive outbreaks and induce debilitating and potentially life-threatening disease manifestations. This systematic review and...

Background and purpose — Understanding the key drivers of hospital variation in postoperative infections after hip fracture surgery is important for directing quality improvements. Therefore, we investigated variation in the risk of any infection, and subgroups of infections including pneumonia and sepsis after hip fracture surgery. Methods — In this nationwide population-based cohort study, all Danish patients aged ≥ 65 undergoing surgery for an incident hip fracture from 2012 to 2017 were included. Risk of postoperative infections, based on data from hospital registration (hospital-treated infections) and antibiotic dispensing (community-treated infections), were calculated using multilevel Poisson regression analysis. Hospital variation was evaluated by intra-class coefficient (ICC) and median risk ratio (MRR). Results — The risk of hospital-treated infection was 15%. The risk of community-treated infection was 24%. The adjusted risk varied between hospitals from 7.8–25% for hospital-treated infection and 16–34% for community-treated infection. The ICC indicated that 19% of the adjusted variance was due to hospital level for hospital-treated infection. The ICC for community-treated infections was 13%. The MRR showed a 2-fold increased risk for the average patient acquiring a hospital-treated infection at the highest risk hospital compared with the lowest risk hospital. For community-treated infection, the MRR was 1.4. Interpretation — Our results suggest that 20% of infections could be reduced by applying the top performing hospitals’ approach. Nearly a 5th of the variation was at the hospital level. This suggests a more standardized approach to avoid postoperative infection after hip fracture surgery. Hip fracture is a leading cause of hospital admission among the elderly. The 30-day mortality following hip fracture surgery has been approximately 10% during the last few years in Denmark (Pedersen et al. 2017). Higher mortality after hip fracture has been associated with a range of hospital factors (Kristensen et al. 2016, Sheehan et al. 2016) and patient factors in observational studies (Roche et al. 2005). Furthermore, variation in 30-day mortality after hip fracture surgery has been observed between Danish hospitals, but not fully explained (Kristensen et al. 2019).

It is still under debate that red blood cell (RBC) transfusions might increase the risk of healthcare-associated infections after hip fracture surgery. Previously, we found that a liberal RBC transfusion strategy improved survival in nursing home residents. Our aim, therefore, was to investigate whether a more liberal RBC transfusion strategy was associated with a higher infection risk in frail elderly hip fracture patients. Prospective, assessor-blinded, randomized and controlled trial. Orthopedic ward, Geriatric ward, and Hospital-at-home. 284 consecutively hospital-admitted elderly with hip fracture from nursing homes or sheltered housing facilities were included. A restrictive RBC transfusion strategy (hemoglobin <9.7g/dL; 6mmol/L) compared with a liberal strategy (hemoglobin <11.3g/dL; 7mmol/L) administered within 30days after surgery. Leukocytes and C-reactive protein (CRP) in repeated blood samples within 30days, and number of all infections (pneumonia, urinary tract infection, and other infections) within 10days. 88% of the patients received a RBC transfusion. A median of 1 RBC unit (interquartile range (IQR): 1-2) was transfused for the restrictive strategy group versus 3 RBC units (IQR: 2-5) for the liberal group. Leukocytes and CRP measurements were similar for both groups. Rates of infection were 72% for the restrictive group compared to 66% for the liberal group (risk ratio 1.08; 95% confidence interval 0.93-1.27, p value 0.29). A more liberal RBC transfusion strategy was not associated with higher risk of infection among residents from nursing homes or sheltered housing undergoing hip fracture surgery.

Background and Aims Kidney transplantation (KTx) remains the most effective type of kidney replacement therapy. Infectious complications remain a common cause of mortality, especially during the first year after KTx. Goal of effective immunosuppressive treatment (IS) must be balanced between the decreasing incidence of acute rejection by maintaining effective levels of IS and at the same time avoiding the incidence of infectious complications caused by dose-dependent toxicity of IS. Method The aim of our analysis was to identify the risk of fixed daily doses of mycophenolic acid (MPA) and concentration controlled doses of tacrolimus (TAC) in the development of a single, recurrent infection and acute rejection after KTx. Results Our analysis consisted of 100 patients after KTx (66 males, 34 females) with anti-thymocyte globulin as an induction IS. We monitored the incidence of single, recurrent infection in 1st month, from 1st to 6th month and from 6th to 12th month after KTx and the incidence of acute kidney rejection in 1st year after KTx. According to multivariant analysis, Daily dose of MPA &amp;gt; 1080 mg and levels of TAC above recommended levels were not independent risk factors for the incidence of the infection. Daily dose of MPA &amp;gt; 1080 mg was a risk factor for recurrent infection in general (OR 1.2964; P = 0.0277), for recurrent bacterial infection from 1st to 6th month (OR 1.2674; P = 0.0151), recurrent bacterial infection (OR 1.2574; P = 0.0436), single viral infection (OR 1.2640; P = 0.0398) from 6th to 12th month after KTx We did not confirmed levels of TAC, above recommended levels in observed periods, as a risk factor for single or recurrent infection regardless of its etiology. We confirmed, incidence of mycotic infection in 1st month after KTx correlated with average level of TAC (13.4 ± 3.2 ng/ml) (P = 0.0300) and with average MPA daily doses (1200 ± 360 mg/day) (P = 0.0203). Correlation between the average daily doses of MPA (730 ± 380 mg/day) and the incidence of bacterial infection (P = 0.0161) and viral infection (P = 0.0161) from 1st to 6th month after KTx were found. We confirmed correlation between the incidence of bacterial infection and the average daily doses of MPA (630 ± 340 mg/day) from 6th to 12th month after KTx (P = 0.0479). By probit dose regression, we confirmed statistical significance between levels of TAC and the incidence of bacterial, mycotic and multidrug-resistant (MDR) infection, correlation between the daily dose of MPA and the incidence of mycotic infection in 1st month after KTx. We found statistical significance between levels of TAC and MDR infection and daily dose of MPA and the incidence of bacterial, mycotic and MDR infection from 1st to 6th month after KTx and we found statistical significance between the daily dose of MPA and the incidence of MDR infection from 6th to 12th month after KTx. In our study, we did not confirmed statistical significance between levels of TAC, daily dose of MPA and the incidence of acute kidney rejection. By logistic regression, neither levels of TAC below recommended values nor daily dose of MPA &amp;lt; 1080 mg were found as an independent risk factors for the incidence of acute kidney rejection. Conclusion In our analysis, we found dose of MPA &amp;gt; 1080 mg/day as a risk factor for recurrent infection starting in the 1st month after KTx and correlation between the incidence of the infections and daily dose of MPA 1 month after KTx, with significant association between the incidence of infections and daily doses of MPA and levels of TAC, without increased risk of acute kidney rejection. In the centers with fixed dosing of IS, this can lead to lowering the risk of infections by decreasing daily doses of MPA 1 month after KTx without increasing risk of infections.

Introduction:Obesity is an oft-cited cause of surgical morbidity and many institutions require extensive supplementary screening for obese patients prior to surgical intervention. However, in the elderly patients, obesity has been described as a protective factor. This article set out to examine the effect of body mass index (BMI) on outcomes and morbidity after hip fracture surgery.Methods:The National Surgical Quality Improvement Program database was queried for all patients undergoing 1 of 4 surgical procedures to manage hip fracture between 2008 and 2012. Patient demographics, BMI, and known factors that lead to poor surgical outcomes were included as putative predictors for complications that included infectious, cardiac, pulmonary, renal, and neurovascular events. Using χ2 tests, 30-day postoperative complication rates were compared between 4 patient groups stratified by BMI as low weight (BMI < 20), normal (BMI = 20-30), obese (BMI = 30-40), and morbidly obese (BMI > 40).Results:A total of 15 108 patients underwent surgery for hip fracture over the examined 5-year period. Of these, 18% were low weight (BMI < 20), 67% were normal weight (BMI = 20-30), 13% were obese (BMI = 30-40), and 2% were morbidly obese (BMI > 40). The low-weight and morbidly obese patients had both the highest mortality rates and the lowest superficial infection rates. There was a significant increase in blood transfusion rates that decreased linearly with increasing BMI. Deep surgical site infection and renal failure increased linearly with increasing BMI, however, these outcomes were confounded by comorbidities.Conclusion:This study demonstrates that patients at either extreme of the BMI spectrum, rather than solely the obese, are at greatest risk of major adverse events following hip fracture surgery. This runs contrary to the notion that obese hip fracture patients automatically require additional preoperative screening and perioperative services, as currently implemented in many institutions.

The objective of the study was to comprehensively synthesise the components of integrated clinical pathways (ICPs) and post-operative outcomes of patients undergone total hip and knee arthroplasty (THA & TKA) and hip fracture surgeries. Previous systematic reviews examined components and effectiveness of ICPs for lower limb joint replacement and hip fracture surgeries. An updated systematic review guided by the Whittemore and Knafl (2005) framework. Electronic databases, Ovid MEDLINE, EBSCOhost-CINAHL, the Cochrane Reviews and Trails, EMBASE and PubMed, were searched from 2007 to 31January 2021. Due to the heterogeneity of the methods and data collection tools of included studies, pooling of the quantitative data was not possible. Therefore, the included studies were synthesised and presented narratively under subthemes of arthroplasty and hip fracture surgeries. The PRISMA checklist for systematic reviews was used. Twenty-four studies met selection criteria with 11 examined ICPs for hip fracture and 13 for the THA and TKA. Twenty-one ICPs were reviewed, and 33 components were extracted. The most frequently included components for hip fracture subgroup were 'discharge disposition arrangement' and 'dedicated personnel and resources'. 'Exercise plan' and 'pain management' were for the arthroplasty subgroup. A significant reduction in the length of stay and post-operative complications were associated with the ICPs. Results were mixed for the effectiveness of ICPs in reducing unplanned hospital admissions, mortality rates, post-operative complications and hospital costs. The number of ICP components varied across studies. This review could not recommend a one size-fits-all ICP that could be adapted for use for patients undergoing hip fracture and joint replacement surgeries. This review identified research evidence-based components considered as essential for the inclusion in ICP's for hip fracture and arthroplasty surgeries. Further research is suggested to determine the patient experience and healthcare providers' acceptance of ICPs.