Outcome Of Hip Fracture Patients Research Articles

Outcome of Centenarians with Hip Fracture: An Analysis of the Registry for Geriatric Trauma (ATR-DGU)

Background/Objectives: Outcomes for hip fracture patients have improved over the years, yet the population of older patients (≥80 years) continues to grow. By 2100, the global centenarian population is projected to exceed 25 million, but data on hip fracture outcomes in this group are rare and often derived from small samples. This study aimed to analyze outcomes for centenarian hip fracture patients in specialized geriatric trauma centers and compare them with those of patients under 80. Methods: We conducted a retrospective analysis of the AltersTraumaRegister DGU® from 2016 to 2022, including all proximal femur fracture data. Patients were categorized into two groups: under 80 years and centenarians. The primary outcome was in-hospital mortality, with secondary outcomes including quality of life, walking ability on postoperative day seven, length of hospital stay, readmission rates, and changes in living situations. Results: Among 14,521 patients, 316 were over 99 years old. In-house mortality was significantly higher in centenarians (15.44% vs. 3.58%; p < 0.001), with more discharged to nursing homes. After matching by the Geriatrics at Risk (GeRi) score, mortality differences diminished. Conclusions: While age is a risk factor for mortality, centenarian hip fracture patients’ outcomes do not significantly differ from those aged ≤80 when considering other risk factors.

Validation of the Geriatrics at Risk Score (GeRi-Score) on 120-day follow-up, the influence of preoperative geriatric visits, and the time to surgery on the outcome of hip fracture patients: an analysis from the Registry for Geriatric Trauma (ATR-DGU).

Numerous tools predict mortality among patients with hip fractures, but they include many variables, require time-consuming assessment, and are difficult to calculate. The GeRi-Score provides a quick method of pre-operative assessment. The aim of this study is to validate the score in the 120-day follow-up and determine the impact of a pre-operative visit by a geriatrician and timing of surgery on the patient outcome. A retrospective analysis of the AltersTraumaRegister DGU® from 2017 to 2021 was conducted, including all proximal femur fractures. The patients were divided into low-, moderate-, and high-risk groups based on the GeRi-Score. Mortality was analyzed using logistic regression. To determine the influence of the time to surgery and the preoperative visit by a geriatrician, matching was performed using the exact GeRi-Score, preoperative walking ability, type of fracture, and the time to surgery. The study included 38,570 patients, divided into 12,673 low-risk, 18,338 moderate-risk, and 7,559 high-risk patients. The moderate-risk group had three times the mortality risk of the low-risk group (OR 3.19 (95% CI 2.68-3.79; p<0.001)), while the high-risk group had almost eight times the mortality risk than the low-risk group (OR 7.82 (95% CI 6.51-9.93; p<0.001)). No advantage was found for surgery within the first 24 h across all groups. There was a correlation of a preoperative geriatric visit and mortality showing an increase in the moderate and high-risk group on in-house mortality. The GeRi-Score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h. The analysis did not demonstrate a benefit of the preoperative geriatric visit, but more data are needed.

Comparative Analysis of Frailty Scores for Predicting Adverse Outcomes in Hip Fracture Patients: Insights from the United States National Inpatient Sample.

The aim of the current investigation was to compare the ability of several frailty scores to predict adverse outcomes in hip fracture patients. All adult patients (18 years or older) who suffered a hip fracture due to a fall and underwent surgical fixation were extracted from the 2019 National Inpatient Sample (NIS) Database. A combination of logistic regression and bootstrapping was used to compare the predictive ability of the Orthopedic Frailty Score (OFS), the Nottingham Hip Fracture Score (NHFS), the 11-factor modified Frailty Index (11-mFI) and 5-factor (5-mFI) modified Frailty Index, as well as the Johns Hopkins Frailty Indicator. A total of 227,850 patients were extracted from the NIS. In the prediction of in-hospital mortality and failure-to-rescue (FTR), the OFS surpassed all other frailty measures, approaching an acceptable predictive ability for mortality [AUC (95% CI): 0.69 (0.67-0.72)] and achieving an acceptable predictive ability for FTR [AUC (95% CI): 0.70 (0.67-0.72)]. The NHFS demonstrated the highest predictive ability for predicting any complication [AUC (95% CI): 0.62 (0.62-0.63)]. The 11-mFI exhibited the highest predictive ability for cardiovascular complications [AUC (95% CI): 0.66 (0.64-0.67)] and the NHFS achieved the highest predictive ability for delirium [AUC (95% CI): 0.69 (0.68-0.70)]. No score succeeded in effectively predicting venous thromboembolism or infections. In summary, the investigated frailty scores were most effective in predicting in-hospital mortality and failure-to-rescue; however, they struggled to predict complications.

The Association between Vitamin D Deficiency and the Risk of Mortality after Hip Fractures: A Systematic Review and Meta-Analysis.

Prevalence of hip fractures is on the rise and is associated with high mortality, especially in aging patients. Vitamin D is routinely recommended for bone health in general population. Our study explores the potential association between low levels (≤20 ng/mL) of vitamin D and mortality in hip fracture patients. Systematic search was done for studies that were published from inception until May 10, 2023, and that report a possible correlation between low vitamin D levels and mortality in patients with hip fractures. A random-effects model was used to assess the effects of normal vitamin D levels on mortality, subgroup analyses were conducted to assess the link between low levels of vitamin D and geographic location of the study and its impact on the recovery process. In 575 identified studies, 18 met the inclusion criteria. A strong connection between low serum levels of vitamin D (<20 ng/mL) and mortality (hazard ratio (HR): 2.29, p<0.001). Further analysis indicated that insufficient (20 to 30 ng/mL) and sufficient (>30 ng/mL) levels of vitamin D levels did not have a significant association with the mortality (HR: 1.10, p=0.12), and (HR: 1.04, p=0.50). As shown by subgroup analysis vitamin D deficiency significantly correlated with mortality in studies conducted in Europe (HR: 2.4). Our results clearly demonstrate that vitamin D deficiency is associated with higher risk of mortality in hip fracture patients. Additional analyses demonstrate that insufficient and sufficient levels of vitamin D were not significantly associated with mortality outcomes in hip fracture patients.

The Impact of Hospital Transfers on Surgical Delay and Associated Postoperative Outcomes for Hip Fracture Patients in Scotland: A Cohort Study.

Background/Objectives: Hip fractures exert a substantial burden on hospital systems. Within Scotland 20% of the population resides rurally, warranting investigation of how this impacts prompt access to surgical care. This study aims to determine whether indirect hospital admission via hospital transfer affects the likelihood of surgical management within 36 h for hip fracture patients. Methods: A retrospective cohort study was performed. This used Scottish Hip Fracture Audit data including patients aged ≥50 split into two propensity matched groups based on their transfer status. Descriptive analysis compared patient characteristics. Regression assessed achieving surgery within 36 h of admission in the unmatched and matched cohorts. Secondary outcomes included time to surgery, mortality, mobilization, returning to residence and length of stay. A sensitivity analysis was undertaken to assess for residual confounding effects. Results: The unmatched analysis included 20,132 patients. Transfer patients were younger (p = 0.007) and less-comorbid (p < 0.001). In the matched population, 711 (63.6%) transfer patients had surgery with 36 h of presentation to hospital, compared to 852 (75.3%) non-transfer patients. Transfer patients had 43% reduced odds of timely surgery (OR (95% CI) 0.57 (0.48 to 0.69); p < 0.001). No disparities emerged in mortality, mobilisation or returning to residence., Transfer patients experienced a significant increase in length of stay in hospital (median (IQR) 16 (8 to 33) vs. 13 (8 to 30); p = 0.024). Conclusions: Hospital transfer is associated with significantly reduced odds of timely surgery, a longer time to surgery and longer length of stay. Development of structured network pathways that minimize delay to transfer are required to potentially optimize outcomes and reduce associated cost.

Outcomes of Patients with Preoperative Thrombocytosis After Hip Fracture Surgery.

Low platelet counts have clinically relevant effects on patient outcomes after hip fracture surgery; however, the relationship between abnormally high platelet counts and postoperative outcomes in this population is unknown. The ACS-NSQIP database was queried for patients who underwent hip fracture surgery between 2015 and 2019. Outcomes were compared between patients with normal platelet counts (150,000 to 450,000/μL) and thrombocytosis (>450,000/μL). Eighty-six thousand three hundred eleven hip fracture patients were identified, of which 1067 (1.2%) had preoperative thrombocytosis. Compared with patients with normal platelet counts, patients with preoperative thrombocytosis had increased rates of 30-day mortality (6.4% vs 4.5%, P = 0.004; OR 1.15 [95% CI 0.88 to 1.50], P = 0.322) as well as increased rates and odds of readmission (11.4% vs 7.8%, P < 0.001; OR 1.35 [95% CI 1.10 to 1.65], P = 0.004) and venous thromboembolic events (3.2% vs 1.7%, P < 0.001; OR 1.88 [95% CI 1.31 to 2.71], P < 0.001). Hip fracture patients with preoperative thrombocytosis had increased rates of early mortality as well as increased odds of venous thromboembolic events and readmission. A patient with thrombocytosis may benefit from close postoperative surveillance and careful follow-up. Future prospective studies are needed to verify causation and investigate how to mitigate adverse outcomes in hip fracture patients with preoperative thrombocytosis.

A quasi-experimental evaluation of the association between implementation of Quality-Based Procedures funding for hip fractures and improvements in processes and outcomes for hip fracture patients in Ontario: an interrupted time series analysis.

In 2013, Ontario introduced a patient-based funding model for hip fracture care (Quality-Based Procedures [QBP]). The association of QBP implementation with changes in processes and outcomes has not been evaluated. We conducted a quasi-experimental study using linked health data for adult hip fractures as an interrupted time series. The pre-QBP period was from 2008 to 2012 and the post-QBP period was from 2014 to 2018; 2013 was excluded as a wash-in period. We used segmented regression analyses to estimate the association of QBP implementation with changes in processes (surgery in less than two days from admission, use of echocardiography, use of nerve blocks, and provision of geriatric care) and clinical outcomes (90-day mortality, 90-day readmissions, length of stay, and days alive at home). We estimated the immediate (level) change, trend (slope) postimplementation, and total counterfactual differences. Sensitivity analyses included case-mix adjustment and stratification by hospital type and procedure. We identified 45,500 patients in the pre-QBP period and 41,256 patients in the post-QBP period. There was a significant total counterfactual increase in the use of nerve blocks (11.1%; 95% confidence interval [CI], 6.2 to 16.0) and a decrease in the use of echocardiography (-2.5%; 95% CI, -3.7 to -1.3) after QBP implementation. The implementation of QBP was not associated with a clinically or statistically meaningful change in 90-day mortality, 90-day readmission, length of stay, or number of days alive at home. Evaluation of the QBP program is crucial to inform ongoing and future changes to policy and funding for hip fracture care. The introduction of the QBP Hip Fracture program, supported by evidence-based recommendations, was associated with improved application of some evidence-based processes of care but no changes in clinical outcomes. There is a need for ongoing development and evaluation of funding models to identify optimal strategies to improve the value and outcomes of hip fracture care. Open Science Framework ( https://osf.io/2938h/ ); first posted 13 June 2022.

Incidence, Quality of Care, and Mortality in Hip Fracture Patients in the Course of the COVID Pandemic: A Population-Based Cohort Study.

We assessed the incidence, quality of in-hospital care, and mortality for hip fracture (HF) patients in Denmark before and during the coronavirus disease (COVID) pandemic. We obtained data from the Danish registries in the COVID period (March 11, 2020 to January 27, 2021, overall and in 5 periods) and compared it to a pre-COVID period (March 13, 2019 to March 10, 2020). We calculated the proportion of patients (%) that have fulfilled all the relevant quality indicators (a composite score of 100%) and adjusted hazard ratios (HR) with a 95% confidence interval (CI) for 30-day mortality. The incidence of HF was 5.7 per 1000 person-years both in pre-COVID and COVID periods. About 35% of patients had a composite score of 100% in the COVID period compared to 28% in the pre-COVID period (proportion ratio 1.23 [95% CI: 1.17-1.30]). Fulfillment of all individual quality indicators was similar or higher in the COVID period. 30-day mortality was 9.5% in pre-COVID period, compared to 10.8% in the COVID period (HR 1.15 [95% CI: 1.02-1.30]). HRs varied from 1.07 (95% CI: 0.89-1.29) to 1.31 (95% CI: 1.06-1.62) in 5 COVID periods. In-hospital mortality was 4% in pre-COVID versus 4.4% in COVID period. The incidence of HF in Denmark remained unchanged. The quality of in-hospital care was higher in the COVID compared to pre-COVID period. Unfortunately, 30-day mortality was also higher, highlighting the importance of recognizing diversity of social networks, home support, and digital health intervention after discharge for outcome of HF patients.

Demographic, functional and clinical characteristics in hip fracture patients according to mental status of the Spanish National Hip Fracture Registry

ObjectiveTo describe the differences according to mental status at admission on the care process and 30-day outcomes in hip fracture patients, mainly regarding the use of rehabilitation resources and anti-osteoporotic medication, by analysing data from the Spanish National Hip Fracture Registry (RNFC, “Registro Nacional de Fracturas de Cadera” in Spanish). MethodsWe analysed prospectively collected data from a cohort of patients admitted participating in the Spanish National Hip Fracture Registry (RNFC) in 76 Spanish hospitals between 2017 and 2019. We classified participants using Short Portable Mental Status Questionnaire (SPMSQ), defining two groups: patients with ≤2 SPMSQ score and patients with >2 SPMSQ score. ResultsOf 21,254 patients was recorded SPMSQ in 17,242 patients, 9052 were >2 SPMSQ score (52.6%). These were older (87.7 vs. 85.3 years; p<0.001), had worse mobility (no-independent walking ability 26.0% vs. 4.5%; p<0.001) and were more likely to be living in nursing homes (35.3% vs. 9.6%; p<0.001). They were more likely to be treated nonoperatively (3.8% vs. 1.5%; p>0.001), less early mobilisation (57.5% vs. 68.9%; p<0.001) and suffered higher in-hospital mortality (5.2% vs. 2.7%; p<0.001). At discharge, they received less anti-osteoporotic medication (37.9% vs. 48.9%; p<0.001) and returned home less often (29.8%% vs. 51.2%; p<0.001). One month after fracture, patients with >2 SPMSQ score had poorer mobility (no-independent walking ability 44.4% vs. 24.9%; p<0.001) and were newly institutionalised in a nursing home more (12.6% vs. 12.0%; p<0.001) and were more likely to die by one-month post-fracture (9.5% vs. 4.6%; p<0.001). ConclusionRNFC patients with >2 SPMSQ score were more vulnerable and had poorer outcomes than patients with ≤2 SPMSQ score, suggesting that they need specialised care in-hospital and in the recovery phase.

Does vitamin D deficiency affect functional outcomes in hip fracture patients? A meta-analysis of cohort studies.

Vitamin D deficiency is common in patients with hip fractures and may negatively affect functional recovery and quality of life (QOL). This study aimed to conduct a meta-analysis to quantify the effects of vitamin D deficiency on physical function and quality of life after hip fractures. The PubMed, EMBASE, Scopus, and Cochrane Library databases were searched for relevant studies. The inclusion criteria were hip fracture, comparison between vitamin D deficiency and normal vitamin D levels in patients with hip fracture, and functional outcome as the primary outcome. The exclusion criteria were case reports, reviews, duplicates, studies with a high risk of bias, and non-comparable or missing data. Two independent reviewers selected studies, extracted data, assessed bias, and performed meta-analyses using the Review Manager. Heterogeneity and publication bias were also assessed. Two independent reviewers selected the studies, extracted data, and assessed the risk of bias. We performed a meta-analysis using Review Manager and assessed heterogeneity and publication bias. Seven studies with 1,972 patients were included. Vitamin D deficiency was defined as a 25(OH)D level < 20ng/mL. There were no significant differences in the ability to walk (OR 0.68, 95% CI 0.31-1.53, I2 = 69%) or length of hospital stay (MD 2.27days, 95% CI -2.47 to 7.01, I2 = 93%) between patients with and without vitamin D deficiency. However, patients with vitamin D deficiency had significantly worse functional ability and quality of life (SMD -1.50, 95% CI -2.88 to -0.12, I2 = 96%). Despite the limitations of this study, such as small sample size, heterogeneous outcome assessments, and variable vitamin D measurement techniques, the results demonstrated that screening for vitamin D status and optimizing levels through supplementation could facilitate rehabilitation, promote lifestyle changes, aid in the recovery of independence, and help reduce long-term burdens.

Outcomes of hip fracture treatment with intravenous morphine and with other analgesics: postoperative analgesic medical expense, severity of pain and hospitalisation—a retrospective study

AimsThis study compares the postoperative medical costs and outcomes of hip fracture patients treated with intravenous (IV) versus other analgesics (weak opioids, NSAIDs or acetaminophen).MethodsWe performed a retrospective study at a tertiary hospital in Thailand, examining 1,531 patients who underwent hip fracture surgery between 2009 and 2020. We analyzed data on analgesic usage, costs, pain scores, and adverse effects.ResultsIn the study of 1531 patients, 63% of patients received as-needed analgesics, and 37% received preemptive prescriptions. In both groups, IV morphine was the predominant choice. The mean cost for the IV group was marginally higher than the other analgesics group ($2277 vs $2174). The other analgesics group had a significantly higher consumption of acetaminophen and selective NSAIDs (p = 0.004). Pain scores were similar across both groups, but the IV group had a significantly higher incidence of gastrointestinal side effects (24% vs 10.5%, p < 0.01).ConclusionThe choice of IV or other analgesics in treating hip fractures affects analgesic usage, side effects, medical costs, and patient outcomes. Further studies across different regions are recommended.

Dementia and Hip Fractures

» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a “orthogeriatric” team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.

Patient-clinician digital health interventions for the hip fracture population: a scoping review

IntroductionOlder adults with hip fracture often require extensive post-surgery care across multiple sectors, making follow-up care even more important to ensure an ideal recovery. With the increased adoption of technology, patient-clinician digital health interventions can potentially improve post-surgery outcomes of hip fracture patients by helping them and their caregivers better understand the various aspects of their care, post-hip fracture surgery. The purpose of this study was to examine the available literature on the impact of hip fracture-specific, patient-clinician digital health interventions on patient outcomes and health care delivery processes. We also aimed to identify the barriers and enablers to the uptake and implementation of these technologies and to provide strategies for improved use of these digital health interventions.MethodsWe conducted a scoping review following the six stages of Arksey and O’Malley’s framework and following the PRISMA-ScR reporting format. Searches were conducted in five databases. In addition to hand searching for relevant studies from the references of all included studies, we also conducted a grey literature search to identify relevant primary studies. Screening of titles and abstracts as well as full texts were performed independently by two reviewers. Two reviewers also performed the data extraction of the included studies.ResultsAfter screening 3,638 records, 20 articles met the criteria and 1 article was identified through hand searching. Various patient-clinician digital health interventions were described including telehealth /telerehabilitation programs (n = 6), care transition /follow-up interventions (n = 5), online resources (n = 2), and wearable devices /sensor monitoring (n = 1). Outcomes were varied and included functional status, gait/mobility, quality of life, psychological factors, satisfaction, survival/complications, caregiver outcomes, compliance, technology-user interactions, and feedback on the use of the digital health interventions. For clinicians, a key barrier to the use of the digital health interventions was the acceptability of the technology. However, the usefulness of the digital health intervention by clinicians was seen as both a barrier and an enabler. For patients and caregivers, all the themes were seen as both a barrier and an enabler depending on the study. These themes included: 1) availability and access, 2) usability, 3) knowledge and skills, 4) acceptability, and 5) usefulness of the digital health intervention.ConclusionMany behavioural factors affect the use of patient-clinician digital health interventions. However, a specific attention should be focused on the acceptability of the technology by the clinicians to encourage uptake of the digital health interventions. The results of this scoping review can help to better understand the factors that may be targeted to increase the use of these technologies by clinicians, patients, and caregivers.

Machine learning-based mortality prediction in hip fracture patients using biomarkers.

The purpose of this retrospective study was to assess whether mortality following a hip fracture can be predicted by a machine learning model trained on basic blood and lab test data as well as basic demographic data. Additionally, the purpose was to identify the key variables most associated with 1-, 5-, and 10-year mortality and investigate their clinical significance. Input data included 3751 hip fracture patient records sourced from the Medical Information Mart for Intensive Care IV database, which provided records from in-hospital database systems at the Beth Israel Deaconess Medical Center. The 1-year mortality rate for all patients studied was 21% and for those aged 80+ was 29%. We assessed 10 different machine learning classification models, finding LightGBM to have the strongest 1-year mortality prediction performance, with accuracy of 81%, AUC of 0.79, sensitivity of 0.34, and specificity of 0.98 on the test set. The strongest-weighted features of the 1-year model included age, glucose, red blood cell distribution width, mean corpuscular hemoglobin concentration, white blood cells, urea nitrogen, prothrombin time, platelet count, calcium levels, and partial thromboplastin time. Most of these were also in the top 10 features of the LightGBM 5- and 10-year prediction models trained. Testing for these high-ranking biomarkers in new hip fracture patients can aid clinicians in assessing the likelihood of poor outcomes for hip fracture patients, and additional research can use these biomarkers to develop a mortality risk score.

Serum biomarkers related to frailty predict negative outcomes in older adults with hip fracture.

Hip fracture is a public health problem worldwide. Traditional prognostic models do not include blood biomarkers, such as those obtained by proteomics. This study aimed to investigate the relationships between serum inflammatory biomarkers and frailty in older adults with hip fracture as well as adverse outcomes at one and three months after discharge. A total of 45 patients aged 75 or older who were admitted for hip fracture were recruited. At admission, a Comprehensive Geriatric Assessment (CGA) was conducted, which included a frailty assessment using the Clinical Frailty Scale (CFS). Blood samples were collected before surgery. Participants were followed up at one and three months after discharge. The levels of 45 cytokines were analyzed using a high-throughput proteomic approach. Binary logistic regression was used to determine independent associations with outcomes, such as functional recovery, polypharmacy, hospital readmission, and mortality. The results showed that IL-7 (OR 0.66 95% CI 0.46-0.94, p = 0.022) and CXCL-12 (OR 0.97 95% CI 0.95-0.99, p = 0.011) were associated with better functional recovery at three months after discharge, while CXCL-8 (OR 1.07 95% CI 1.01-1.14, p = 0.019) was associated with an increased risk of readmission. These findings suggest that immunology biomarkers may represent useful predictors of clinical outcomes in hip fracture patients.

Frailty and post-operative delirium influence on functional status in patients with hip fracture: the GIOG 2.0 study

BackgroundThis study analyzes the effect of frailty and Post-Operative Delirium (POD) on the functional status at hospital discharge and at 4-month follow-up in patients with hip fracture (HF).MethodsMulticenter prospective observational study of older patients with HF admitted to 12 Italian Orthogeriatric centers (July 2019-August 2022). POD was assessed using the 4AT. A 26-item Frailty Index (FI) was created using data collected on admission. The outcome measures were Cumulated Ambulation Score (CAS) ≤ 2 at discharge and a telephone-administered CAS ≤ 2 after 4 months. Poisson regression models were used to assess the effect of frailty and POD on outcomes.Results984 patients (median age 84 years, IQR = 79–89) were recruited: 480 (48.7%) were frail at admission, 311 (31.6%) developed POD, and 158 (15.6%) had both frailty and POD. In a robust Poisson regression, frailty alone (Relative Risk, RR = 1.56, 95% Confidence Intervals, CI 1.19–2.04, p = 0.001) and its combination with POD (RR = 2.57, 95% CI 2.02–3.26, p < 0.001) were associated with poor functional status at discharge. At 4-month follow-up, the combination of frailty with POD (RR 3.65, 95% CI 1.85–7.2, p < 0.001) increased the risk of poor outcome more than frailty alone (RR 2.38, 95% CI 1.21–4.66, p < 0.001).ConclusionsPOD development exacerbates the negative effect that frailty exerts on functional outcomes in HF patients.

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants.

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

Poorly controlled diabetes: Glycosylated hemoglobin (HA1c) levels >8% are the tipping point for significantly worse outcomes following hip fracture in the geriatric population

The presence of diabetes has been associated with increased mortality risk after hip fracture, however, little has been published about the lab values of these diabetic patients and the role high labs play in morbidity and mortality. The purpose of this study is to quantify the severity of diabetes that is associated with worse outcomes in hip fracture patients. A consecutive series of 2430 patients >55 years old who sustained a hip fracture between October 2014-November 2021 were reviewed for demographics, hospital quality measures, and outcomes. Each patient with a diagnosis of diabetes mellitus (DM) was reviewed for hemoglobin-A1c (HA1c) and glucose values at admission. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of diabetes and elevated lab values (HA1c) on outcomes such as hospital quality measures, inpatient complications, readmission rates, and mortality rates. 565 patients (23%) carried a diagnosis of diabetes mellitus at the time of their injury. Considerable demographic and comorbidity differences between diabetic and non-diabetic cohorts indicated that the diabetic cohort was less healthy. The diabetic cohort had longer hospitalizations, higher rates of minor complications, readmissions within 90-days, and mortality within 30-days/1-year. Stratification by HA1c levels found patients with a HA1c>8% had a significantly higher rate of major complications, and mortality at all time points (inpatient/30-day/1-year). Multivariable regression found HA1c>8% to be independently associated with a higher rate of inpatient/30-day/1-year mortality in comparison to a diagnosis of diabetes alone which was not independently significant. While all patients with DM experienced worse outcomes than those without, those with poorly controlled diabetes (HA1c>8%) at the time of hip fracture injury experienced poorer outcomes compared to those with well-controlled diabetes. Treating physicians must recognize these patients with poorly controlled DM at the time of arrival to adjust care planning and patient expectations accordingly.

Validation and updating of the Older Person's Emergency Risk Assessment (OPERA) score to predict outcomes for hip fracture patients.

Hip fractures are associated with significant morbidity and mortality in older people. Accurate risk stratification is important for planning of care, informed decision-making and communication with patients and relatives. The Older Persons' Emergency Risk Assessment (OPERA) score is a risk stratification score for older people admitted to hospital. Our aims were to validate OPERA in hip fracture patients, update the score and compare performance with the Nottingham Hip Fracture Score (NHFS). This dual-centre 3-year observational study (2016-2018) included acutely admitted hip fracture patients managed surgically aged ⩾65 years. The primary outcome was 30-day mortality. Secondary outcomes included residence at 120 days and 1-year mortality. Model performance was assessed using area under the curve (AUC) analysis and Brier scores (discrimination) and calibration curves. The OPERA score was updated using regression analysis with additional independent predictors and validated using bootstrap analysis. 2142 patients (median age 86 [80-91] years) were included with a 30-day mortality of 5.2% and a 1-year mortality of 31.4%. 30-day mortality AUC for OPERA was 0.75 (95% CI, 0.73-0.77) and for NHFS 0.68 (0.65-0.70). For 1-year mortality AUC for OPERA was 0.74 (0.73-0.75) and for NHFS 0.70 (0.69-0.71). The OPERA Score was updated to Hip-OPERA, including ASA grade. Hip-OPERA demonstrated an AUC for 30-day mortality of 0.77 (0.73-0.81) and an AUC for 1-year mortality of 0.76 (0.75-0.77). AUC for new residential care status at 120 days was 0.79 (0.78-0.80). Hip-OPERA demonstrated superior discrimination to the NHFS and OPERA for 30-day mortality, 1-year mortality and residence at 120 days following hip fracture. External validation is desirable.

Postsurgery paths and outcomes for hip fracture patients (POST-OP HIP PATHS): a population-based retrospective cohort study protocol

IntroductionHip fracture patients receive varying levels of support posthip fracture surgery and often experience significant disability and increased risk of mortality. Best practice guidelines recommend that all hip fracture patients...