Variation in care and outcomes for people after hip fracture with and without cognitive impairment; results from the Australian and New Zealand Hip Fracture Registry.

BACKGROUND: People with dementia have poorer outcomes after hip fracture and this may be due in part to variation in care. We aimed to compare care and outcomes for people with and without cognitive impairment after hip fracture. METHODS: Retrospective cohort study using Australian and New Zealand Hip Fracture Registry data for people ≥50 years of age who underwent hip fracture surgery (n = 49,063). Cognitive impairment or known dementia and cognitively healthy groups were defined using preadmission cognitive status. Descriptive statistics and multivariable mixed effects models were used to compare groups. RESULTS: In general, cognitively impaired people had worse care and outcomes compared to cognitively healthy older people. A lower proportion of the cognitively impaired group had timely pain assessment (≤30 min of presentation: 61% vs 68%; p < 0.0001), were given the opportunity to mobilise (89% vs 93%; p < 0.0001) and achieved day-1 mobility (34% vs 58%; p < 0.0001) than the cognitively healthy group. A higher proportion of the cognitively impaired group had delayed pain management (>30 mins of presentation: 26% vs 20%; p < 0.0001), were malnourished (27% vs 15%; p < 0.0001), had delirium (44% vs 13%; p < 0.0001) and developed a new pressure injury (4% vs 3%; p < 0.0001) than the cognitively healthy group. Fewer of the cognitively impaired group received rehabilitation (35% vs 64%; p < 0.0001), particularly patients from RACFs (16% vs 39%; p < 0.0001) and were prescribed bone protection medication on discharge (24% vs 27%; p < 0.0001). Significantly more of the cognitively impaired group had a new transfer to residential care (46% vs 11% from private residence; p < 0.0001) and died at 30-days (7% vs 3% from private residence; 15% vs 10% from RACF; both p < 0.0001). In multivariable models adjusting for covariates with facility as the random effect, the cognitively impaired group had a greater odds of being malnourished, not achieving day-1 walking, having delirium in the week after surgery, dying within 30 days, and in those from private residences, having a new transfer to a residential care facility than the cognitively healthy group. CONCLUSIONS: We have identified several aspects of care that could be improved for patients with cognitive impairment - management of pain, mobility, nutrition and bone health, as well as delirium assessment, prevention and management strategies and access to rehabilitation. Further research is needed to determine whether improvements in care will reduce hospital complications and improve outcomes for people with dementia after hip fracture.

Improving hip fracture care: A five-year review of the early contributors to the Australian and New Zealand Hip Fracture Registry.

OBJECTIVE: The aim of this study was to examine temporal trends (2016-2020) in hip fracture care in Australian and New Zealand (ANZ) hospitals that started providing patient-level data to the ANZ Hip Fracture Registry (ANZHFR) on/before 1 January 2016 (early contributors). METHODS: Retrospective cohort study of early contributor hospitals (n = 24) to the ANZHFR. The study cohort included patients aged ≥50 years admitted with a low trauma hip fracture between 1 January 2016 and 31 December 2020 (n = 26,937). Annual performance against 11 quality indicators and 30- and 365-day mortality were examined. RESULTS: Compared to 2016/2017, year-on-year improvements were demonstrated for preoperative cognitive assessment (2020: OR 3.57, 95% confidence interval [95% CI] 3.29-3.87) and nerve block use prior to surgery (2020: OR 4.62, 95% CI 4.17-5.11). Less consistent improvements over time from 2016/2017 were demonstrated for emergency department (ED) stay of <4 h (2017; 2020), pain assessment ≤30 min of ED presentation (2020), surgery ≤48 h (2020) and bone protection medication prescribed on discharge (2017-2020; 2020 OR 2.22, 95% CI 2.03-2.42). The odds of sustaining a hospital-acquired pressure injury increased in 2019-2020 compared to 2016. The odds of receiving an orthogeriatric model of care and being offered the opportunity to mobilise on Day 1 following surgery fluctuated. There was a reduction in 365-day mortality in 2020 compared to 2016 (OR 0.86, 95% CI 0.74-0.98), whereas 30-day mortality did not change. CONCLUSIONS: Several quality indicators improved over time in early contributor hospitals. Indicators that did not improve may be targets for future care improvement activities, including considering incentivised hip fracture care, which has previously been shown to improve care/outcomes. COVID-19 and reporting practices may have impacted the study findings.

Time to interval cholecystectomy and associated outcomes in a population aged 50 and above with mild gallstone pancreatitis.

BACKGROUND: Cholecystectomy on index admission for mild gallstone pancreatitis (GSP) is recommended, although not always feasible. This study examined rates and outcomes of people aged ≥ 50 years who underwent interval (delayed) cholecystectomy at increasing time points. METHODS: Hospitalisation and death data were linked for individuals aged ≥ 50 years admitted to hospital in New South Wales, Australia with mild GSP between 2008-2018. Primary outcome was interval cholecystectomy timing. Secondary outcomes included mortality, emergency readmission for gallstone-related disease (GSRD) (28 and 180-day), and length of stay (LOS) (index admission and total six-month GSRD). RESULTS: 3,003 patients underwent interval cholecystectomy: 861 (28.6%) at 1-30, 1,221 (40.7%) at 31-90 and 921 (30.7%) at 91-365 days from index admission. There was no difference in 365-day mortality between groups. Longer delay to cholecystectomy was associated with increased 180-day emergency GSRD readmission (17.5% vs 15.8% vs 19.9%, p < 0.001) and total six-month LOS (5.9 vs 8.4 vs 8.3, p < 0.001). Endoscopic retrograde cholangiopancreatography (ERCP) was increasingly required with cholecystectomy delay (14.5% vs 16.9% vs 20.4%, p < 0.001), as were open cholecystectomy procedures (4.8% vs 7.6% vs 11.3%, p < 0.001). Extended delay was associated with patients of lower socioeconomic status, regional/rural backgrounds or who presented to a low volume or non-tertiary hospital (p < 0.001). CONCLUSION: Delay to interval cholecystectomy results in increased rates of emergency readmission, overall LOS, risks of conversion to open surgery and need for ERCP. Index admission cholecystectomy is still recommended, however when not possible, interval cholecystectomy should be performed within 30 days to minimise patient risk and healthcare burden.

The impact of fixation type for intertrochanteric femoral fracture on patient survival.

BACKGROUND: Intramedullary (IM) nail fixation for intertrochanteric fractures is potentially associated with improved postoperative function but may have an increased mortality risk compared to sliding hip screw (SHS) fixation. This study investigated postoperative mortality risk between surgical fixation type for intertrochanteric fracture in patients aged 50 years and older using linked data from the Australian Hip Fracture Registry and National Death Index. METHODS: Descriptive analysis and Kaplan-Meier survival curves performed unadjusted analysis of mortality and fixation type (short IM nail, long IM nail and SHS). Multilevel logistic regression (AMLR) and Cox modelling (CM) performed adjusted analysis of fixation type and mortality following surgery. Instrumental variable analysis (IVA) was conducted to minimize the effect of unknown confounders. RESULTS: The 30-day mortality was 7.1% for short IM, 7.8% for long IM and 7.8% for SHS fixation (P = 0.2). The AMLR demonstrated significant increase in 30-day mortality risk for long IM nail compared to short IM nail (OR = 1.2, 95% CI = 1.0-1.4, P < 0.05) but no significant difference for SHS fixation (OR = 1.1, 95% CI = 0.9-1.3, P = 0.5). No significant difference between groups and postoperative mortality was demonstrated by the CM at 30-days nor 1-year nor by the IVA at 30-days. CONCLUSION: Despite a significant increase in 30-day mortality risk for long IM nail compared to short IM nail fixation in the adjusted analysis, this was not demonstrated in the CM nor IVA indicating the role of confounders influencing the regression findings. There was no significant association in 1-year mortality between long IM nail and SHS compared to short IM nail fixation.

The impact of cement fixation on early mortality in arthroplasty for hip fracture.

Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture. This retrospective cohort study used linked data from the Australian Hip Fracture Registry and the National Death Index. Descriptive analysis and Kaplan-Meier survival curves tested the unadjusted association of mortality between cemented and uncemented procedures. Multilevel logistic regression, adjusted for covariates, tested the association between cement use and 30-day mortality following arthroplasty. Given the known institutional variation in preference for cemented fixation, an instrumental variable analysis was also performed to minimize the effect of unknown confounders. Adjusted Cox modelling analyzed the association between cement use and mortality at 30 days and one year following surgery. The 30-day mortality was 6.9% for cemented and 4.9% for uncemented groups (p = 0.003). Cement use was significantly associated with 30-day mortality in the Kaplan-Meier survival curve (p = 0.003). After adjusting for covariates, no significant association between cement use and 30-day mortality was shown in the adjusted multilevel logistic regression (odd rati0 (OR) 1.1, 95% confidence interval (CI) 0.9 to 1.5; p = 0.366), or in the instrumental variable analysis (OR 1.0, 95% CI 0.9 to 1.0, p=0.524). There was no significant between-group difference in mortality within 30days (hazard ratio (HR) 0.9, 95% CI 0.7to 1.1; p = 0.355) or one year (HR 0.9 95% CI 0.8 to 1.1; p = 0.328) in the Cox modelling. No statistically significant difference in patient mortality with cement use in arthroplasty was demonstrated in this population, once adjusted for covariates. This study concludes that cementing in arthroplasty for hip fracture is a safe means of surgical fixation.

Lesbian, gay, bisexual, transgender and gender diverse and queer (LGBTQ) community members' perspectives on palliative care in New South Wales (NSW), Australia.

Lesbian, gay, bisexual, transgender and gender diverse people, and queer people (LGBTQ people) are at increased risk of some chronic diseases and cancers. NSW Health palliative care health policy prioritises equitable access to quality care, however, little is known about community members' perspectives on palliative care. This study aimed to understand LGBTQ community views and preferences in palliative care in NSW. A community survey and follow-up interviews with LGBTQ people in NSW were conducted in mid-2020. A total of 419 people responded to the survey, with 222 completing it. Six semi-structured phone interviews were conducted with participants who volunteered for follow-up. The sample included LGBTQ people with varied levels of experience in palliative care. Thematic analysis was conducted on survey and interview data, to identify perceived barriers and enablers, and situate these factors in the socio-ecological model of health. Some perceived barriers from community members related to considering whether to be 'out' (i.e., making one's sexual orientation and gender known to services), knowledge and attitudes of staff, concern about potential substandard care or mistreatment (particularly for transgender health), decision making, biological family as a source of tension, and loneliness and isolation. Perceived enablers related to developing and distributing inclusive palliative care information, engaging with community(ies), fostering inclusive and non-discriminatory service delivery, ensuring respectful approaches to person-centred care, and staff training on and awareness building of LGBTQ needs and issues. Most of the participants who had experienced palliative care recounted positive interactions, however, we identified that LGBTQ people require better access to knowledgeable and supportive services. Palliative care information should be inclusive and services respectful and welcoming. Particular consideration should be given to how services respond to and engage with people from diverse population groups. These insights can support ongoing policy and service development activities to further enhance palliative care.

Does identifying frailty from ICD-10 coded data on hospital admission improve prediction of adverse outcomes in older surgical patients? A population-based study.

BACKGROUND: frailty is a major contributor to poor health outcomes in older people, separate from age, sex and comorbidities. This population-based validation study evaluated the performance of the International Classification of Diseases, 10th revision, coded Hospital Frailty Risk Score (HFRS) in the prediction of adverse outcomes in an older surgical population and compared its performance against the commonly used Charlson Comorbidity Index (CCI). METHODS: hospitalisation and death data for all individuals aged ≥50 admitted for surgery to New South Wales hospitals (2013-17) were linked. HFRS and CCI scores were calculated using both 2- and 5-year lookback periods. To determine the influence of individual explanatory variables, several logistic regression models were fitted for each outcome of interest (30-day mortality, prolonged length of stay (LOS) and 28-day readmission). Area under the receiving operator curve (AUC) and Akaike information criterion (AIC) were assessed. RESULTS: of the 487,197 patients, 6.8% were classified as high HFRS, and 18.3% as high CCI. Although all models performed better than base model (age and sex) for prediction of 30-day mortality, there was little difference between CCI and HFRS in model discrimination (AUC 0.76 versus 0.75), although CCI provided better model fit (AIC 79,020 versus 79,910). All models had poor ability to predict prolonged LOS (AUC range 0.62-0.63) or readmission (AUC range 0.62-0.65). Using a 5-year lookback period did not improve model discrimination over the 2-year period. CONCLUSIONS: adjusting for HFRS did not improve prediction of 30-mortality over that achieved by the CCI. Neither HFRS nor CCI were useful for predicting prolonged LOS or 28-day unplanned readmission.

Clothing-related burns in New South Wales, Australia: impact of legislation on a continuing problem.

To combat the risk of nightwear burns a mandatory standard regulating the design, flammability and labelling requirements of children's nightwear was introduced in Australia in 1987. This population-based study examined the trends, characteristics and causes of clothing-related burns to inform a review of the current standard, and to facilitate the development of targeted prevention strategies. Clothing-related burns for 1998-2013 were identified from hospitalisation data for all hospitals in NSW and detailed information regarding circumstance of injury from a burn data registry. To investigate percentage annual change (PAC) in trends negative binomial regression analysis was performed. There were 541 hospitalisations for clothing-related burns, 18% were nightwear-related and 82% were for other clothing. All clothing burns decreased by an estimated 4% per year (95% CI -6.2 to -2.1). Nightwear-related burns decreased by a significantly higher rate (PAC -7.4%; 95% CI -12.5 to -2.1) than other clothing (PAC -2.5%; 95%CI -4.7 to -0.1). Exposure to open heat source (campfire/bonfire) was the most common cause, followed by cooking. Of factors known to be associated with clothing burns, accelerant use was reported in 27% of cases, cigarettes 17%, loose skirt or dress 8%, and angle grinders in 6% of cases. Hospitalisations for clothing burns are relatively uncommon in NSW and rates, particularly of nightwear burns, have decreased over the last 15 years. Strategies for continued reduction of these injuries include increasing the scope of the current clothing standard or developing new standards to include all children's clothing and adult nightwear, and increasing community awareness of the risk associated with open heat sources, accelerant use and loose clothing.

The impact of recent changes in smoke alarm legislation on residential fire injuries and smoke alarm ownership in New South Wales, Australia.

In 2006, New South Wales (NSW) state legislation changed from requiring smoke alarms in new houses only to all houses. We evaluated the impact of this legislative change on residential fire injury and smoke alarm ownership characteristics. Residential fire injuries for 2002 to 2010 were identified from hospitalization data for all hospitals in NSW. Data relating to smoke alarm ownership and demographic factors were obtained from the NSW Population Health Survey. Negative binomial regression analysis was used to analyze trends over time. Prior to the introduction of universal legislation, hospitalization rates were increasing slightly; however, following the introduction of legislation, hospitalization rates decreased by an estimated 36.2% (95% confidence interval [CI], 16.7-55.8) annually. Smoke alarm ownership increased from 73.3% (95% CI, 72.5-74.2) prelegislation to 93.6% (95% CI, 93.1-94.2) 18 months postlegislation. Thirty percent of households reported testing their alarms regularly. Speaking a language other than English (relative risks [RRs], 1.82; 95% CI, 1.44-2.99), allowing smoking in the home (RR, 1.73; 95% CI, 1.31-2.27), and being part of the most disadvantaged socioeconomic group (RR, 1.47; 95% CI, 1.14-1.91) remain major risk factors for nonownership. Broadening the scope of state legislation has had a positive impact on residential fire-related hospitalizations and smoke alarm ownership. However, it is of concern that the legislation has been the least effective in increasing smoke alarm ownership among non-English-speaking households, in households where smoking is allowed, in low socioeconomic households, and that a high proportion of householders do not test their smoke alarms regularly. Targeted campaigns are needed to reach these high-risk groups and to ensure that smoke alarms are functional.