RESUMO
PURPOSE: This study aimed to develop and validate clinical prediction models using machine learning (ML) algorithms for reliable prediction of subsequent hip fractures in older individuals, who had previously sustained a first hip fracture, and facilitate early prevention and diagnosis, therefore effectively managing rapidly rising healthcare costs in China. METHODS: Data were obtained from Grade A Tertiary hospitals for older patients (age ≥ 60 years) diagnosed with hip fractures in southwest China between 1 January 2009 and 1 April 2020. The database was built by collecting clinical and administrative data from outpatients and inpatients nationwide. Data were randomly split into training (80%) and testing datasets (20%), followed by six ML-based prediction models using 19 variables for hip fracture patients within 2 years of the first fracture. RESULTS: A total of 40,237 patients with a median age of 66.0 years, who were admitted to acute-care hospitals for hip fractures, were randomly split into a training dataset (32,189 patients) and a testing dataset (8,048 patients). Our results indicated that three of our ML-based models delivered an excellent prediction of subsequent hip fracture outcomes (the area under the receiver operating characteristics curve: 0.92 (0.91-0.92), 0.92 (0·92-0·93), 0.92 (0·92-0·93)), outperforming previous prediction models based on claims and cohort data. CONCLUSIONS: Our prediction models identify Chinese older people at high risk of subsequent hip fractures with specific baseline clinical and demographic variables such as length of hospital stay. These models might guide future targeted preventative treatments.
Assuntos
Fraturas do Quadril , Idoso , Humanos , Algoritmos , Custos de Cuidados de Saúde , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/prevenção & controle , Aprendizado de Máquina , Fatores de Risco , Pessoa de Meia-IdadeRESUMO
PURPOSE: The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture. METHODS: Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients. RESULTS: A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients. CONCLUSION: A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.
Assuntos
Idoso Fragilizado , Avaliação Geriátrica , Fraturas do Quadril , Cuidados Pré-Operatórios , Humanos , Fraturas do Quadril/cirurgia , Fraturas do Quadril/diagnóstico , Avaliação Geriátrica/métodos , Idoso de 80 Anos ou mais , Feminino , Idoso , Masculino , Cuidados Pré-Operatórios/métodos , Casas de Saúde , Institucionalização/estatística & dados numéricos , Testes Diagnósticos de RotinaRESUMO
INTRODUCTION: 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). METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
Assuntos
Artroplastia de Quadril , Fraturas do Quadril , Humanos , Idoso , Idoso de 80 Anos ou mais , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/cirurgia , Medição de Risco , Fatores de Risco , Morbidade , Mortalidade Hospitalar , Estudos RetrospectivosRESUMO
OBJECTIVES: To evaluate 2 prognostic models for mortality after a fracture of the hip, the Nottingham Hip Fracture Score and Hip Fracture Estimator of Mortality Amsterdam and to compare their predictive performance to physician assessment of mortality risk in hip fracture patients. DESIGN: Prospective cohort study. SETTING: Two level-2 trauma centers located in the Netherlands. PATIENTS: Two hundred forty-four patients admitted to the Emergency Departments of both hospitals with a fractured hip. INTERVENTION: Data used in both prediction models were collected at the time of admission for each individual patient, as well as predictions of mortality by treating physicians. MAIN OUTCOME MEASURES: Predictive performances were evaluated for 30-day, 1-year, and 5-year mortality. Discrimination was assessed with the area under the curve (AUC); calibration with the Hosmer-Lemeshow goodness-of-fit test and calibration plots; clinical usefulness in terms of accuracy, sensitivity, and specificity. RESULTS: Mortality was 7.4% after 30 days, 22.1% after 1 year, and 59.4% after 5 years. There were no statistically significant differences in discrimination between the prediction methods (AUC 0.73-0.80). The Nottingham Hip Fracture Score demonstrated underfitting for 30-day mortality and failed to identify the majority of high-risk patients (sensitivity 33%). The Hip fracture Estimator of Mortality Amsterdam showed systematic overestimation and overfitting. Physicians were able to identify most high-risk patients for 30-day mortality (sensitivity 78%) but with some overestimation. Both risk models demonstrated a lack of fit when used for 1-year and 5-year mortality predictions. CONCLUSIONS: In this study, prognostic models and physicians demonstrated similar discriminating abilities when predicting mortality in hip fracture patients. Although physicians overestimated mortality, they were better at identifying high-risk patients and at predicting long-term mortality. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas do Quadril , Médicos , Fraturas do Quadril/diagnóstico , Mortalidade Hospitalar , Humanos , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Hip fracture is frequent in older people and represents a major public health issue worldwide. The increasing incidence of hip fracture and the associated hospitalization costs place a significant economic burden on older patients and their families. On January 1, 2018, the Chinese diagnosis-related group (C-DRG) payment system, which aims to reduce financial barriers, was implemented in Sanming City, southern China. This study aimed to evaluate the associations of C-DRG system with inpatient expenditures for older people with hip fracture. METHODS: An uncontrolled before-and-after study employed data of all the patients with hip fracture aged 60 years or older from all the public hospitals enrolled in the Sanming Basic Health Insurance Scheme from January 1, 2016 to December 31, 2018. The 'pre C-DRG sample' included patients from January 1, 2016 to December 31, 2017. The 'post C-DRG sample' included patients from January 1, 2018 to December 31, 2018. A propensity score matching analysis was used to adjust the difference in baseline characteristic parameters between the pre and post samples. Data were analyzed using generalized linear models adjusted for the demographic, clinical, and institutional factors. Robust tests were performed by accounting for time trend, the fixed effects of the year and hospitals, and clustering effect within hospitals. RESULTS: After propensity score matching, we obtained two homogeneous groups of 1123 patients each, and the characteristic variables of the two matched groups were similar. We found that C-DRG reform was associated with a 19.51% decrease in out-of-pocket (OOP) payments (p < 0.001) and a 99.93% decrease in OOP payments as a share of total inpatient expenditure (p < 0.001); whereas total inpatient expenditure was not significantly associated with the C-DRG reform. All the sensitivity analyses did not change the results significantly. CONCLUSION: The implementation of C-DRG payment system reduced both the absolute amount of OOP payments and OOP payments as a share of total inpatient expenditure for older patients with hip fracture, without affecting total inpatient expenditure. These results may provide significant insights for policymakers in reducing the financial burden on older patients with hip fracture in other countries.
Assuntos
Gastos em Saúde , Fraturas do Quadril , Idoso , China/epidemiologia , Grupos Diagnósticos Relacionados , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/terapia , Humanos , Pacientes InternadosRESUMO
ABSTRACT: To investigate the influencing factors of fracture nonunion after intramedullary nailing for subtrochanteric fractures and to construct a risk assessment model.Based on the multicenter retrospective analysis of 251 patients, all patients were divided into modeling group and verification group. In the modeling group, postoperative fracture nonunion rate, general data, fracture-related factors, surgical reduction-related factors, mechanical and biological factors were calculated, and the influencing factors of fracture nonunion were screened by univariate analysis. Logistic regression model was used for multifactor analysis to construct the risk assessment model. Based on the logistic regression model, the risk prediction model was constructed by drawing the Nomogram diagram. Through the verification group, the influencing factors were evaluated again, and the differentiation and calibration of the model were evaluated. The calibration degree was evaluated by Hosmer-Lemeshow test, goodness of fit test, and calibration curve. The discriminant degree was evaluated by the receiver operating characteristic curve.Fracture nonunion occurred in 34 of 149 patients in the modeling group. Among the 14 potential influencing factors, univariate analysis and logistic regression analysis showed that postoperative hip varus, intramedullary nail fixation failure, and reduction of fracture with large incision were the risk factors of fracture nonunion. The medial cortex fracture was seen reduced on X-Ray was a protective factor for fracture nonunion, and a regression equation was established. Based on the logistic regression model, the Nomogram diagram is drawn. Twenty-four cases of fracture nonunion occurred in the verification group. The area under the receiver operating characteristic curve was area under curve =0.883â>â0.7, indicating that there was a moderate differentiation to evaluate the occurrence of fracture nonunion after operation. The goodness of fit test: the Hosmers-Lemeshow test (X2â=â2.921, Pâ=â.712â>â.05) showed that the model had a good calibration.After intramedullary nailing of subtrochanteric fracture, hip varus, failure of intramedullary nail fixation and wide surgical dissection are the risk factors of fracture nonunion, and the postoperative reduction of medial cortex fracture is protective factor.National key research and development projects: 2016YFC0105806.
Assuntos
Coxa Vara , Fixação Intramedular de Fraturas , Fraturas não Consolidadas , Fraturas do Quadril/cirurgia , Complicações Pós-Operatórias , Medição de Risco , Idoso , Pinos Ortopédicos , Coxa Vara/diagnóstico , Coxa Vara/epidemiologia , Feminino , Fixação Intramedular de Fraturas/efeitos adversos , Fixação Intramedular de Fraturas/instrumentação , Fixação Intramedular de Fraturas/métodos , Fraturas não Consolidadas/diagnóstico , Fraturas não Consolidadas/epidemiologia , Fraturas não Consolidadas/etiologia , Fraturas do Quadril/diagnóstico , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/epidemiologia , Masculino , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Radiografia/métodos , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Falha de TratamentoRESUMO
BACKGROUND: About 50% of all hospitalized fragility fracture cases in older Americans are hip fractures. Approximately 3/4 of fracture-related costs in the USA are attributable to hip fractures, and these are mostly covered by Medicare. Hip fracture patients with dementia, including Alzheimer's disease, have worse health outcomes including longer hospital length of stay (LOS) and charges. LOS and hospital charges for dementia patients are usually higher than for those without dementia. Research describing LOS and acute care charges for hip fractures has mostly focused on these outcomes in trauma patients without a known pre-admission diagnosis of osteoporosis (OP). Lack of documented diagnosis put patients at risk of not having an appropriate treatment plan for OP. Whether having a diagnosis of OP would have an effect on hospital outcomes in dementia patients has not been explored. We aim to investigate whether having a diagnosis of OP, dementia, or both has an effect on LOS and hospital charges. In addition, we also report prevalence of common comorbidities in the study population and their effects on hospital outcomes. METHODS: We conducted a cross-sectional analysis of claims data (2012-2013) for 2175 Medicare beneficiaries (≥65 years) in the USA. RESULTS: Compared to those without OP or dementia, patients with demenia only had a shorter LOS (by 5%; P = .04). Median LOS was 6 days (interquartile range [IQR]: 5-7), and the median hospital charges were $45,100 (IQR: 31,500 - 65,600). In general, White patients had a shorter LOS (by 7%), and those with CHF and ischemic heart disease (IHD) had longer LOS (by 7 and 4%, respectively). Hospital charges were 6% lower for women, and 16% lower for White patients. CONCLUSION: This is the first study evaluating LOS in dementia in the context of hip fracture which also disagrees with previous reporting about longer LOS in dementia patients. Patients with CHF and IHD remains at high risk for longer LOS regardless of their diagnosis of dementia or OP.
Assuntos
Fraturas do Quadril , Osteoporose , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/terapia , Humanos , Tempo de Internação , Masculino , Medicare , Osteoporose/diagnóstico , Osteoporose/epidemiologia , Osteoporose/terapia , Estados Unidos/epidemiologiaRESUMO
Methods for identifying patients at high risk for osteoporotic fractures, including dual-energy X-ray absorptiometry (DXA)1,2 and risk predictors like the Fracture Risk Assessment Tool (FRAX)3-6, are underutilized. We assessed the feasibility of automatic, opportunistic fracture risk evaluation based on routine abdomen or chest computed tomography (CT) scans. A CT-based predictor was created using three automatically generated bone imaging biomarkers (vertebral compression fractures (VCFs), simulated DXA T-scores and lumbar trabecular density) and CT metadata of age and sex. A cohort of 48,227 individuals (51.8% women) aged 50-90 with available CTs before 2012 (index date) were assessed for 5-year fracture risk using FRAX with no bone mineral density (BMD) input (FRAXnb) and the CT-based predictor. Predictions were compared to outcomes of major osteoporotic fractures and hip fractures during 2012-2017 (follow-up period). Compared with FRAXnb, the major osteoporotic fracture CT-based predictor presented better receiver operating characteristic area under curve (AUC), sensitivity and positive predictive value (PPV) (+1.9%, +2.4% and +0.7%, respectively). The AUC, sensitivity and PPV measures of the hip fracture CT-based predictor were noninferior to FRAXnb at a noninferiority margin of 1%. When FRAXnb inputs are not available, the initial evaluation of fracture risk can be done completely automatically based on a single abdomen or chest CT, which is often available for screening candidates7,8.
Assuntos
Fraturas por Osteoporose/diagnóstico por imagem , Fraturas por Osteoporose/diagnóstico , Medição de Risco , Tomografia Computadorizada por Raios X , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Automação , Biomarcadores/metabolismo , Calibragem , Feminino , Fraturas por Compressão/diagnóstico , Fraturas por Compressão/diagnóstico por imagem , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Curva ROC , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/diagnóstico por imagemAssuntos
Índice de Massa Corporal , Efeitos Psicossociais da Doença , Fraturas do Quadril/epidemiologia , Inquéritos Nutricionais , Sobrepeso/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Fraturas do Quadril/diagnóstico , Humanos , Masculino , Inquéritos Nutricionais/métodos , Obesidade/diagnóstico , Obesidade/epidemiologia , Sobrepeso/diagnósticoRESUMO
To assess the cost-effectiveness of the primary prevention of fragility hip fractures through opportunistic risk-based screening using FRAX® among women aged 70 to 89 years, and the subsequent treatment with alendronate in women at high-risk, from the Spanish national health system perspective. We performed a discrete-event simulation model. Women were categorized in low, intermediate and high-risk of fragility hip fracture through screening based on the FRAX® risk assessment tool score (Spanish version). Low-risk women received lifestyle recommendations whereas the high-risk group was assigned to alendronate treatment. For women at intermediate-risk, treatment decision was based on a recalculated score considering bone mineral density (BMD). The cost-effectiveness analysis tested six scenarios defined by different FRAX® cut-off values assessing the incremental costs per averted fracture in 20 years. Deterministic sensitivity analysis was performed. We included a random sample of 5146 women obtained from a Spanish cohort of women referred for BMD. The most cost-effective intervention had an Incremental Cost-effectiveness Ratio (ICER) of 57,390 per averted hip fracture and consisted of using the FRAX® score without BMD and treating women with a score higher than 5%. The ICER exceeded the acceptability threshold of 25,000 in all the scenarios. Sensitivity analysis based on time to fracture, treatment efficacy, adherence to treatment and cost of dependence resulted in ICERs ranging from 39,216 to 254,400 . An ICER of 24,970 was obtained when alendronate cost was reduced to 1.13 per month. The use of FRAX® as screening tool followed by alendronate treatment is not cost-effective in senior women in Spain. Other primary preventions strategies are advisable.
Assuntos
Densidade Óssea , Fraturas do Quadril/diagnóstico , Programas de Rastreamento , Fraturas por Osteoporose/diagnóstico , Prevenção Primária , Absorciometria de Fóton , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Feminino , Fraturas do Quadril/economia , Fraturas do Quadril/epidemiologia , Humanos , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Modelos Econômicos , Osteoporose Pós-Menopausa/complicações , Osteoporose Pós-Menopausa/diagnóstico , Osteoporose Pós-Menopausa/epidemiologia , Fraturas por Osteoporose/economia , Fraturas por Osteoporose/epidemiologia , Prevenção Primária/economia , Prevenção Primária/métodos , Medição de Risco , Espanha/epidemiologiaRESUMO
BACKGROUND: Early surgical fixation of femoral neck factures in elderly patients has been suggested to decrease morbidity and mortality and to improve treatment outcome. This study evaluates the effect of the implementation of a diagnosis-related group payment method in our hospital on waiting time for surgery and the short-term outcomes of elderly patients following surgical fixation of hip fractures. METHODS: Demographic and clinical characteristics of 75 consecutive patients, who underwent surgery for hip fracture in our hospital, before the implementation of a diagnosis-related group payment method, were compared with those of 75 consecutive patients, who were operated on after the implementation of the payment system. RESULTS: Demographic characteristics were similar for both groups. Before the implementation of a diagnosis-related group payment method, 84% of the patients waited longer than 48 hours for surgery, compared to only 24% of patients after the implementation (p<0.001). Medical considerations and operation room availability were the main reasons for delaying surgery in both groups. Mortality and morbidity rates during the hospital stay remained similar, regardless of the implementation of the payment method. CONCLUSIONS: The implementation of a diagnosis-related group payment method shortened the waiting time for surgical hip fixation in elderly patients treated in our hospital, with no effect on the mortality and complication rate during the hospital stay.
Assuntos
Grupos Diagnósticos Relacionados , Fraturas do Colo Femoral , Fraturas do Quadril , Listas de Espera , Idoso , Fraturas do Colo Femoral/diagnóstico , Fraturas do Colo Femoral/economia , Fraturas do Colo Femoral/cirurgia , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/economia , Fraturas do Quadril/cirurgia , Humanos , Tempo de Internação , Resultado do TratamentoRESUMO
The Fracture Risk Assessment Tool (FRAX®) was developed to predict fracture risk in the general population, but its applicability to patients with chronic kidney disease (CKD) is unknown. Using the Manitoba Bone Mineral Density (BMD) Database, we identified adults not receiving dialysis with available serum creatinine measurements and bone densitometry within 1 year. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Incident major osteoporotic fractures and hip fractures were ascertained from population-based health care databases. The performance of FRAX, derived without and with BMD, was studied in relation to CKD stage. Among 10,099 subjects (mean age 64 ± 13 years, 13.0% male), 2,154 had eGFR 30-60 mL/min/1.73 m2 (CKD stage 3) and 590 had eGFR <30 mL/min/1.73 m2 (CKD stages 4-5). During a 5-year observation period, 772 individuals experienced a major osteoporotic fracture and 226 had a hip fracture. FRAX predicted risk for major osteoporotic fracture and hip fracture in all eGFR strata. For every standard deviation increase in FRAX score derived with BMD, the hazard ratio (HR) for hip fracture was 4.54 (95% confidence interval [CI] 3.57-5.77) in individuals with eGFR ≥ 60 mL/min/1.73m2, 4.52 (95% CI 3.15-6.49) in individuals with eGFR 30-60 mL/min/1.73m2, and 3.10 (95% CI 1.80-5.33) in individuals with eGFR <30 mL/min/1.73m2. The relationship between FRAX and major osteoporotic fracture was stronger in those with CKD compared to those with preserved eGFR. These findings support the use of FRAX to risk stratify patients with non-dialysis CKD for major osteoporotic fractures and hip fractures.
Assuntos
Fraturas do Quadril/diagnóstico , Fraturas por Osteoporose/diagnóstico , Insuficiência Renal Crônica/complicações , Idoso , Idoso de 80 Anos ou mais , Densidade Óssea/fisiologia , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/etiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/etiologia , Insuficiência Renal Crônica/fisiopatologia , Medição de Risco/métodos , Fatores de RiscoRESUMO
OBJECTIVE: We estimated the health resource utilization (HRU) and associated costs during the 12months after a first osteoporotic hip fracture (OHF) in six Spanish Regions. METHODS: Observational, prospective study including patients ≥65years-old hospitalized due to a first OHF in: Andalusia, Catalonia, Valencian Community, Galicia, Madrid and the Basque Country. HRU related to OHF, quality of life and patient autonomy were collected, and HRU-associated costs were estimated. RESULTS: Four hundred and eighty-seven patients (mean age: 83.1years, 77% women) were included, with demographic characteristics that were similar across the Regions. Mean hospital stay was longest in Madrid and Galicia (women/men: 15.0/18.6 and 16.9/12.6days, respectively) and shortest in Andalusia and the Valencian Community (8.2/7.2 and 8.4/9.4days). There were more rehabilitation sessions and formal home care days in Catalonia and Madrid (women/men: 16/21 and 17/29 sessions; 19/20 and 30/27days) and fewer in Andalusia and Galicia (4/1 and 3/0 sessions; 3/1 and 1/0days). Mean HRU costs were higher in Madrid and lower in Andalusia (women/men: 12,321/12,297 and 7,031/6,115, respectively). CONCLUSIONS: OHF place a large burden on Spanish Regional Health Systems, including high economic costs. We found notable differences in mean costs across the Regions, mainly caused by the differential length of the first hospital stay and the outpatient care in subsequent months. These differences may be associated with differences in surgical delay. A national consensus on the management of OHF is desirable; moreover, agreeing common guidelines could have major socio-economic and healthcare benefits.
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Custos de Cuidados de Saúde/estatística & dados numéricos , Fraturas do Quadril/economia , Fraturas por Osteoporose/economia , Idoso , Idoso de 80 Anos ou mais , Utilização de Instalações e Serviços/economia , Utilização de Instalações e Serviços/estatística & dados numéricos , Feminino , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/terapia , Humanos , Masculino , Fraturas por Osteoporose/diagnóstico , Fraturas por Osteoporose/terapia , Estudos Prospectivos , EspanhaRESUMO
INTRODUCTION: Osteoporosis and fractures are known to complicate spondyloarthritis (SA). The Fracture Risk Assessment Tool (FRAX) estimate the 10-year probability of major osteoporotic fracture (MOF) and also hip fracture (FH). It can be useful as risk assessment tools for the purpose of preventing fracture in SA. AIM: To measure the bone mineral density (BMD), to evaluate the FRAX and to determinate factors associated with high risk of fracture in patients with SA. METHODS: It's a prospective cross-sectional study that included seventy-five patients admitted for SA, in the rheumatology department of Kassab institute in Tunisia. All of them fulfilled the modified New York criteria for SA. RESULTS: Sixty-two men and thirteen women were enrolled, with mean age of 36.8 ± 11.8 years. The mean age at disease onset was 27.8± 9.9 years. Mean BASDAI and ASDAS CRP were respectively 3.5 ± 2.4 and 3 ± 0.83. The mean BASRI was 8.9 ± 4.2 and the mean mSASSS was 17.6 ± 19.6. Vitamin D insuffiency and deficiency were found in 43 and 30 patients respectively. Osteoporosis (T score ≤ -2,5 SD) were found in 49% of patients and 80 % of them have a reduced BMD (T score ≤ -1 SD). The mean MOF score was 0,36 ± 0,3 [0-0,9] and the mean FH score was 0,3 ± 0 [0-0,5].The MOF was significantly associated with Bone loss (p=0.000). A trend for a significant association was also found with ASDASCRP (p=0.05). The MOF and FH were both significantly associated to the age at the onset of SA (respectively, p=0,003 and p=0,002). The risk of FH was higher when hip BASRI (p=0..036) and ESR were high (p=0,014), it's also associated to age (p=0..002) and vitamin D deficiency (p= 0.043). However, no correlation was found between the MOF and FH and the presence of peripheral arthritis, enthesitis or hip arthritis. CONCLUSION: The MOF score, in patient's wih SA, was associated with bone loss, age at disease onset and ASDASCRP. The HF score was associated with age, Vitamine D deficiency, age at disease onset, high hip BASRI and high ESR.
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Densidade Óssea , Fraturas Ósseas/diagnóstico , Espondilartrite/complicações , Espondilartrite/diagnóstico , Adolescente , Adulto , Idade de Início , Estudos Transversais , Feminino , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/etiologia , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/etiologia , Humanos , Masculino , Osteoporose/complicações , Osteoporose/diagnóstico , Osteoporose/epidemiologia , Fraturas por Osteoporose/diagnóstico , Fraturas por Osteoporose/epidemiologia , Fraturas por Osteoporose/etiologia , Estudos Prospectivos , Projetos de Pesquisa , Medição de Risco/métodos , Fatores de Risco , Espondilartrite/epidemiologia , Espondilartrite/fisiopatologia , Tunísia/epidemiologia , Adulto JovemRESUMO
Although many patients presenting with hip fractures have classic symptoms, other patients may present atypically with referred knee pain and reasonably unremarkable clinical examination following initial presentation. Older patients commonly have comorbid conditions such as arthritis, stroke and dementia that can complicate history and examination, making the diagnosis of subtle fractures difficult. Multimorbidity represents an important diagnostic challenge to both primary and secondary care. This case study discusses a 90-year-old lady who was found to have an old right neck of femur fracture after attendance at an geriatric outpatient clinic for a discussion about anticoagulation, after GP referral.
Assuntos
Artralgia/etiologia , Fraturas do Quadril/complicações , Fraturas do Quadril/diagnóstico , Articulação do Joelho , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial/organização & administração , Anticoagulantes/administração & dosagem , Feminino , Humanos , Atenção Primária à Saúde , Acidente Vascular Cerebral/prevenção & controleRESUMO
BACKGROUND: Acetabular prosthesis positioning in total hip arthroplasty is important in reducing the risk of dislocation. Assessment of version by computed tomography scan is expensive and involves a large radiation dose. We wished to assess the value of Widmer's technique, utilizing readily available radiographs, to determine cup anteversion. METHODS: Patients who underwent primary total hip arthroplasty by the senior author (AGS) at a single regional hospital over a 5-year period were eligible for inclusion. Measurements were performed using the technique described by Widmer, utilizing standard post-operative radiographs. Statistical analysis was undertaken in SPSS v22. Significance was accepted at P < 0.05. RESULTS: Assessment included 109 hips in 99 patients; 63 hips with cemented cups and 46 hips with uncemented cups. Mean acetabular anteversion in the cemented group was 11.9° (0-27.7, SD: 7) and in the uncemented group was 14.1° (10.3-32.7, SD: 7.1); this difference trended towards statistical significance (P = 0.09). Test-retest measurements showed high degree of correlation (Pearson test: 0.927, P < 0.001). There were 96 of 109 hips positioned in the Lewinnek safe zone of 5-25° anteversion. The crude dislocation rate in our cohort was 6.4% (7 of 109 hips) with all dislocations occurring in hips placed in the safe zone. CONCLUSION: Widmer's technique is a reliable method for calculating acetabular version in a regional hospital setting and offers the individual surgeon a ready technique of personal quality control. Cup version was not a significant factor contributing to dislocation rates in our series.
Assuntos
Acetábulo/cirurgia , Artroplastia de Quadril/métodos , Prótese de Quadril , Luxações Articulares/cirurgia , Qualidade de Vida , Idoso , Austrália , Cimentos Ósseos , Estudos de Coortes , Feminino , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/cirurgia , Humanos , Luxações Articulares/diagnóstico , Masculino , Pessoa de Meia-Idade , Osteoartrite do Quadril/diagnóstico , Osteoartrite do Quadril/cirurgia , Desenho de Prótese , Estudos Retrospectivos , Medição de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: Trabecular Bone Score (TBS) is an index of bone microarchitecture that provides additional skeletal information to areal Bone Mineral Density (aBMD). Recently TBS data has been used to optimize the Fracture Risk Assessment Tool (FRAX) predictive value. The aim of this study was to evaluate the clinical value of TBS on FRAX algorithm. MATERIALS AND METHODS: Among total of 358 postmenopausal Iranian women (mean age 61.3 ± 9.5 years) tested for aBMD and TBS, 184 osteopenic women were identified. Thoracolumbar spine X-ray done in all participants revealed twenty-one vertebral fractures. For the osteopenic group, FRAX and TBS adjusted FRAX (FRAX-TBS) were calculated and compared. RESULTS: Mean TBS of the patients was 1.31 (±0.11). A significant correlation was found between TBS and spine aBMD (r = 0.50, p < 0.001) and TBS and femoral neck aBMD (r = 0.37, p < 0.0001). A strong positive correlation was observed between aBMD adjusted FRAX and FRAX-TBS in predicting the risk of major osteoporotic fracture (r = 0.90, p < 0.0001), and hip fracture (r = 0.97, p < 0.0001). According to the area under the receiver operating characteristics curve, the predictive value of the three different models using aBMD, TBS, and combination of aBMD and TBS were similar (0.765, 0.776, and 0.781, respectively; p = 0.19). The proportion of the women needed treatment remained unchanged using FRAX or FRAX-TBS. CONCLUSION: This study showed no clinical benefit for TBS in postmenopausal women. Adding TBS data to aBMD or FRAX neither improved aBMD predictive value for vertebral fracture nor changed the decision on treatment based on FRAX.
Assuntos
Densidade Óssea/fisiologia , Osteoporose Pós-Menopausa/diagnóstico , Fraturas por Osteoporose/diagnóstico , Pós-Menopausa/fisiologia , Absorciometria de Fóton , Idoso , Estudos Transversais , Feminino , Colo do Fêmur/diagnóstico por imagem , Colo do Fêmur/fisiopatologia , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/etiologia , Humanos , Irã (Geográfico) , Pessoa de Meia-Idade , Osteoporose Pós-Menopausa/complicações , Osteoporose Pós-Menopausa/fisiopatologia , Fraturas por Osteoporose/etiologia , Fraturas por Osteoporose/fisiopatologia , Valor Preditivo dos Testes , Medição de Risco , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/etiologia , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/fisiopatologiaRESUMO
More than 1 billion people suffer from chronic respiratory diseases worldwide, accounting for more than 4 million deaths annually. Inhaled corticosteroid is a popular medication for treating chronic respiratory diseases. Its side effects include decreased bone mineral density and osteoporosis. The aims of this study are to investigate the association of inhaled corticosteroids and fracture and to design a clinical support system for fracture prediction. The data of patients aged 20 years and older, who had visited healthcare centers and been prescribed with inhaled corticosteroids within 2002-2010, were retrieved from the National Health Insurance Research Database (NHIRD). After excluding patients diagnosed with hip fracture or vertebrate fractures before using inhaled corticosteroid, a total of 11645 patients receiving inhaled corticosteroid therapy were included for this study. Among them, 1134 (9.7%) were diagnosed with hip fracture or vertebrate fracture. The statistical results showed that demographic information, chronic respiratory diseases and comorbidities, and corticosteroid-related variables (cumulative dose, mean exposed daily dose, follow-up duration, and exposed duration) were significantly different between fracture and nonfracture patients. The clinical decision support systems (CDSSs) were designed with integrated genetic algorithm (GA) and support vector machine (SVM) by training and validating the models with balanced training sets obtained by random and cluster-based undersampling methods and testing with the imbalanced NHIRD dataset. Two different objective functions were adopted for obtaining optimal models with best predictive performance. The predictive performance of the CDSSs exhibits a sensitivity of 69.84-77.00% and an AUC of 0.7495-0.7590. It was concluded that long-term use of inhaled corticosteroids may induce osteoporosis and exhibit higher incidence of hip or vertebrate fractures. The accumulated dose of ICS and OCS therapies should be continuously monitored, especially for patients with older age and women after menopause, to prevent from exceeding the maximum dosage.
Assuntos
Corticosteroides/efeitos adversos , Sistemas de Apoio a Decisões Clínicas , Fraturas do Quadril/diagnóstico , Transtornos Respiratórios/tratamento farmacológico , Fraturas da Coluna Vertebral/diagnóstico , Administração por Inalação , Corticosteroides/administração & dosagem , Adulto , Idoso , Algoritmos , Área Sob a Curva , Densidade Óssea/efeitos dos fármacos , Comorbidade , Bases de Dados Factuais , Feminino , Fraturas do Quadril/complicações , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Osteoporose/induzido quimicamente , Prevalência , Estudos Prospectivos , Transtornos Respiratórios/complicações , Software , Fraturas da Coluna Vertebral/complicações , Máquina de Vetores de Suporte , Taiwan/epidemiologia , Adulto JovemRESUMO
BACKGROUND & AIMS: Cirrhosis, the prevalence of which is increasing, is a risk factor for osteoporosis and fractures. However, little is known of the actual risk of hip fractures in patients with alcoholic cirrhosis. Using linked primary and secondary care data from the English and Danish nationwide registries, we quantified the hip fracture risk in two national cohorts of patients with alcoholic cirrhosis. METHODS: We followed 3,706 English and 17,779 Danish patients with a diagnosis of alcoholic cirrhosis, and we identified matched controls from the general populations. We estimated hazard ratios (HR) of hip fracture for patients vs. controls, adjusted for age, sex and comorbidity. RESULTS: The five-year hip fracture risk was raised both in England (2.9% vs. 0.8% for controls) and Denmark (4.6% vs. 0.9% for controls). With confounder adjustment, patients with cirrhosis had fivefold (adjusted HR 5.5; 95% CI 4.3-6.9), and 8.5-fold (adjusted HR 8.5; 95% CI 7.8-9.3) increased rates of hip fracture, in England and Denmark, respectively. This association between alcoholic cirrhosis and risk of hip fracture showed significant interaction with age (pâ¯<0.001), being stronger in younger age groups (under 45â¯years, HR 17.9 and 16.6 for English and Danish patients, respectively) than in patients over 75â¯years (HR 2.1 and 2.9, respectively). In patients with alcoholic cirrhosis, 30-day mortality following a hip fracture was 11.1% in England and 10.0% in Denmark, giving age-adjusted post-fracture mortality rate ratios of 2.8(95% CI 1.9-3.9) and 2.0(95% CI 1.5-2.7), respectively. CONCLUSIONS: Patients with alcoholic cirrhosis have a markedly increased risk of hip fracture and post-hip fracture mortality compared with the general population. These findings support the need for more effort towards fracture prevention in this population, to benefit individuals and reduce the societal burden. LAY SUMMARY: Alcoholic cirrhosis creates a large public health burden and is a risk factor for bone fractures. Based on data from England and Denmark, we found that hip fractures occur more than five times more frequently in people with alcoholic cirrhosis than in people without the disease. Additionally, the aftermath of the hip fracture is severe, such that up to 11% of patients with alcoholic cirrhosis die within 30â¯days after their hip fracture. These results suggest that efforts directed towards fracture prevention in people with alcoholic cirrhosis could be beneficial.
Assuntos
Fraturas do Quadril , Cirrose Hepática Alcoólica/epidemiologia , Osteoporose/epidemiologia , Fraturas por Osteoporose , Idoso , Efeitos Psicossociais da Doença , Dinamarca/epidemiologia , Inglaterra/epidemiologia , Feminino , Seguimentos , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/diagnóstico , Fraturas por Osteoporose/epidemiologia , Prevalência , Sistema de Registros/estatística & dados numéricos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Fatores de RiscoRESUMO
OBJECTIVES: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures. DESIGN: Retrospective cohort. SETTING: American College of Surgeons Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period. MAIN OUTCOME MEASUREMENTS: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. RESULTS: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.