Orthogeriatric Service Reduces Mortality in Patients With Hip Fracture.

INTRODUCTION: Orthogeriatric service has been shown to improve outcomes in patients with hip fracture. The purpose of this study is to evaluate the effect of orthogeriatrics at Bispebjerg University Hospital, Denmark. The primary outcome is mortality inhospital and after 1, 3, and 12 months for patients with hip fracture. The secondary outcome is mortality for home dwellers and nursing home inhabitants. MATERIALS AND METHODS: This is a retrospective clinical cohort study with an historic control group including all patients with hip fracture admitted from 2007 to 2011. Patients with hip fracture are registered in a local database, and data are retrieved retrospectively using the Danish Civil Registration Number. RESULTS: We included 993 patients in the intervention group and 989 patients in the control group. A univariate analysis showed only significantly decreased mortality inhospital 6.3% vs 3.1% (P = .009) after orthogeriatrics. However, when adjusting for age, gender, and American Society of Anaesthesiologists (ASA) score in a multivariate analysis, including all patients with hip fracture, we find significantly reduced mortality inhospital (odds ratio [OR] 0.35), after 30 [OR 0.66] and 90 days [OR 0.72] and 1 year [OR 0.79]). When using a univariate analysis for home-dwelling patients, we found significantly reduced mortality inhospital (8.3-2.0%, P < .0001), after 30 days (12.2-6.8%, P = .004) and 90 days (20.5-13.0%, P = .002). One-year mortality was not significant. Patients from nursing homes had no significant decreasing mortality at any point of time in the univariate analysis. CONCLUSION: We have shown significant decreases for inhospital, 30 day, 90 day, and 1-year mortality after implementation of orthogeriatric service at Bispebjerg Hospital when adjusting for age, gender, and ASA score. Future trials should include frail patients with other fracture types who can benefit from orthogeriatrics.

Preoperative factors associated with red blood cell transfusion in hip fracture patients.

INTRODUCTION: Red blood cell (RBC) transfusion is a frequently used treatment in patients admitted with a fractured hip, but the use remains an area of much debate. The aim of this study was to determine preoperative factors associated with the risk of receiving a red blood cell transfusion in hip fracture patients. METHOD: The study included 986 consecutive hip fracture patients (aged 60 years or above). The patients were identified from a database of all hip fracture patients admitted to Bispebjerg University Hospital. Data for the database are collected via chart review and data extraction from the hospitals laboratory system, public registries and from the Capital Region Blood Bank Database. RESULTS: Overall transfusion rate was 58.7 %. The univariate analyses showed that transfusion rate was higher among women (p = 0.004), older patients (p < 0.0001), patients with high ASA scores (p < 0.0001), patients with more severe fractures (p < 0.0001), patients with lower admission haemoglobin levels (p < 0.0001), patients not admitted from own home (p = 0.02) and patients taking aspirin (p = 0.007) or other platelet inhibitors (p = 0.01) on admission. In the multivariate analysis, increasing age, ASA ≥3, being admitted from own home, extracapsular fractures, decreasing admission haemoglobin and use of platelet inhibitors were all significantly associated with the risk of receiving a RBC transfusion. CONCLUSION: Several readily available preoperative factors in the form of age, residence, ASA, admission haemoglobin, medication and type of fracture were independently associated with the likelihood of receiving a red blood cell transfusion in patients admitted with a fractured hip.

Metaanalysis of risk factors for mortality in patients with hip fracture.

INTRODUCTION: The aim of this meta-analysis is to assess the association of three different clinical score systems with the mortality in hip fracture patients. METHODS: A literature search was conducted on November 13, 2011 using PubMed and Embase. The search yielded 315 publications which were reviewed on the basis of the inclusion criteria. RESULTS: Thirteen studies were included for further processing. The following clinical score systems were found to be of prognostic value for mortality in hip fracture patients: a high American Society of Anesthesiologists (ASA) score of three or above (odds ratio (OR): 3.07; 95% confidence interval (CI): 2.78-3.38; p < 0.00001, 15,625 study participants included), a Charlson Comorbidity Index (CCI) score of one or more (OR: 2.05; 95% CI: 1.79-2.34; p < 0.00001, 13,570 study participants included) and dementia (assessed with Mini Mental State Examination or obtained from journal extraction) (OR: 2.73; 95% CI: 1.64-4.57; p = 0.0001; 1,782 study participants included). CONCLUSION: The present meta-analysis showed that the ASA score, the CCI score and assessment of preexisting dementia are useful in predicting the mortality of hip fracture patients.

Secondary hyperparathyroidism and mortality in hip fracture patients compared to a control group from general practice.

INTRODUCTION: Previously, little attention has been paid as to how disturbances in the parathyroid hormone (PTH)-calcium-vitamin D-axis, such as secondary hyperparathyroidism (SHPT), relate to mortality amongst hip fracture patients. This study aimed to (1) determine if SHPT is associated with mortality in this group of patients, (2) investigate the association between serum (s-) PTH, s-total calcium, s-25-hydroxyvitamin D (s-25(OH)D) and mortality and (3) determine the prevalence of SHPT amongst hip fracture patients and a control group. METHOD: The study included 562 hip fracture patients (HF) (age ≥ 70 years) admitted to a Danish university hospital. The hip fracture patients were prospectively enrolled in a dedicated hip fracture database. Each hip fracture patient was exactly matched according to age and sex with two controls randomly chosen from a control population of 21,778 subjects who had s-PTH, s-total calcium and s-25(OH)D measured at the Copenhagen General Practitioners Laboratory after referral from their general practitioner. The control group (Con) thus consisted of 1124 subjects. RESULTS: General 1-year mortality: Con-female 8.4%, Con-male 15.3%, HF-female 24.6%, HF-male 33.3%, p<0.0001 (log rank). SHPT AND RELATED 1-YEAR MORTALITY: Con-no SHPT 8.9%, Con-SHPT 16.8%, HF-no SHPT 22.7%, HF-SHPT 34.9%, p<0.0001 (log rank). The mortality rates were higher for controls with SHPT (OR 2.06, 95% CI: 1.32-3.23), hip fracture patients without SHPT (OR 3.00, 95% CI: 2.14-4.20) and hip fracture patients with SHPT (OR 5.46, 95% CI: 3.32-8.97) compared to the controls without SHPT. PREVALENCE OF SHPT: Con 16%, HF 20%, p=0.09 (Chi-square). CONCLUSIONS: Our study clearly shows that SHPT is significantly associated with mortality in both hip fracture patients and the control group. In the multivariate Cox regression analysis, s-PTH and s-total calcium were both significantly associated with mortality, whereas s-25(OH)D was not associated with mortality in this analysis. Our study furthermore indicates that SHPT is almost equally prevalent amongst the hip fracture patients and the control group.

Introduction of new guidelines for emergency patients: motivational counselling among smokers.

INTRODUCTION: Smoking is the most important risk factor for morbidity and mortality in hospital patients. Patient contact with the healthcare system should include smoking cessation counselling. Emergency admissions are seldom given this opportunity. OBJECTIVE: The aim of the study was to illustrate the implementation of motivational counselling in a department of acute surgery. METHODS: Between May 2003 and January 2004, 200 emergency patients were offered motivational counselling and a 6-week smoking cessation programme. RESULTS: We measured the number of patients who accepted motivational counselling. Of the initial 200 patients, 121 (61%) accepted motivational counselling. The only factor related to the level of motivation was age. The most motivated group had an average age of 45 years, whereas the average age of the least motivated group was 64. There was no correlation between the Fagerstrom score, pack-years, gender, illness, employment, or alcohol consumption and the outcome. Fifty-seven patients agreed to us following them up, of which 10% quit smoking for 6 months; 44% either quit or reduced their smoking for a shorter period of time, and 17% of the continuing smokers requested admission to the smoking cessation programme. CONCLUSION: The majority of smokers acutely admitted to an acute orthopaedic department accepted motivational counselling against smoking, the youngest being the most motivated. It appears possible to implement motivational counselling for smoking cessation in an acute orthopaedic department. It is relevant to consider how, and for which groups, a smoking intervention programme can be offered to acutely admitted patients.