Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture.

Malnutrition is very prevalent in geriatric patients with hip fracture. Nevertheless, its importance is not fully recognized. The objective of this paper is to review the impact of malnutrition and of nutritional treatment upon outcomes and mortality in older people with hip fracture. We searched the PubMed database for studies evaluating nutritional aspects in people aged 70 years and over with hip fracture. The total number of studies included in the review was 44, which analyzed 26,281 subjects (73.5% women, 83.6 ± 7.2 years old). Older people with hip fracture presented an inadequate nutrient intake for their requirements, which caused deterioration in their already compromised nutritional status. The prevalence of malnutrition was approximately 18.7% using the Mini-Nutritional Assessment (MNA) (large or short form) as a diagnostic tool, but the prevalence was greater (45.7%) if different criteria were used (such as Body Mass Index (BMI), weight loss, or albumin concentration). Low scores in anthropometric indices were associated with a higher prevalence of complications during hospitalization and with a worse functional recovery. Despite improvements in the treatment of geriatric patients with hip fracture, mortality was still unacceptably high (30% within 1 year and up to 40% within 3 years). Malnutrition was associated with an increase in mortality. Nutritional intervention was cost effective and was associated with an improvement in nutritional status and a greater functional recovery. To conclude, in older people, the prevention of malnutrition and an early nutritional intervention can improve recovery following a hip fracture.

Safe working in a 7-day service. Experience of hip fracture care as documented by the UK National Hip Fracture Database.

Objective: to describe differences in care and 30-day mortality of patients admitted with hip fracture on weekends (Saturday-Sunday) compared to weekdays (Monday-Friday), and their relationship to the organisation of care. Methods: data came from the National Hip Fracture Database (NHFD) linked to ONS mortality data on 52,599 patients presenting to 162 units in England between 1 January and 31 December 2014. This was combined with information on geriatrician staffing and major trauma centre (MTC) status. 30-day mortality and care were compared for patients admitted at weekends and weekdays; separately for patients treated in units grouped by the mean level of input by geriatricians, weekend geriatrician clinical cover and MTC status. Differences were adjusted for variation in patients' characteristics. Results: there was no evidence of differences in 30-day mortality between patients admitted at weekends compared to weekdays (7.2 vs 7.5%, P = 0.3) before or after adjusting for patient characteristics in either MTCs or general hospitals. The proportion receiving a preoperative geriatrician assessment was lower at weekends (42.8 vs 60.7%, P < 0.001). 30-day mortality was lower in units with higher levels of geriatrician input, but there was no weekend mortality effect associated with lower levels of input or absence of weekend cover. Conclusion: there was no evidence of a weekend mortality effect among patients treated for hip fracture in the English NHS. It appears that clinical teams provide comparably safe and effective care throughout the week. However, greater geriatrician involvement in teams was associated with overall lower mortality.

Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models.

Background: our orthopaedic trauma unit serves a large elderly population, admitting 400-500 hip fractures annually. A higher than expected mortality was detected amongst these patients, prompting a change in the hip fracture pathway. The aim of this study was to assess the impact of a change in orthogeriatric provision on hip fracture outcomes and care quality indicators. Patients and Methods: the hip fracture pathway was changed from a geriatric consultation service to a completely integrated service on a dedicated orthogeriatric ward. A total of 1,894 consecutive patients with hip fractures treated in the 2 years before and after this intervention were analysed. Results: despite an increase in case complexity, the intervention resulted in a significant reduction in mean length of stay from 27.5 to 21 days (P < 0.001), a significant reduction in mean time to surgery from 41.8 to 27.2 h (P < 0.001) and a significant 22% reduction in 30-day mortality (13.2-10.3%, P = 0.04). After controlling for the effects of age, gender, American Society of Anesthesiology (ASA) Grade and abbreviated mental test score (AMTS), the effect of integrating orthogeriatric services into the hip fracture pathway significantly reduced the risk of mortality (odds ratio 0.68, P = 0.03). Conclusions: changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly improved mortality and performance indicators. This is the first study to directly compare two accepted models of orthogeriatric care in the same hospital.

Perioperative risk factors in patients with a femoral neck fracture - influence of 25-hydroxyvitamin D and C-reactive protein on postoperative medical complications and 1-year mortality.

BACKGROUND: This study examined the association of 25-hydroxyvitamin D (25(OH)D) and C-reactive protein (CRP) with postoperative medical complications and one year mortality of elderly patients sustaining a low-energy cervical hip fracture scheduled for surgery. We hypothesized that vitamin D deficiency and CRP in these patients might be associated with an increased 1-year mortality. METHODS: The prospective single-center cohort study included 209 patients with a low-energy medial femoral neck fracture; 164 women aged over 50 years and 45 men aged over 60 years. Referring to 1-year mortality and postoperative medical complications multiple logistic regression analysis including 10 co-variables (age, sex, BMI, ASA, creatinine, CRP, leukocytes hemoglobin, 25(OH)D, vitamin D supplementation at follow-up) was performed. RESULTS: Vitamin D deficiency was prevalent in 87 % of all patients. In patients with severe (<10 ng/ml) and moderate (10-20 ng/ml) vitamin D deficiency one year mortality was 29 % and 13 %, respectively, compared to 9 % in patients with > 20 ng/ml 25(OH)D levels (p =0.027). Patients with a mild (CRP 10-39.9 mg/l) or active inflammatory response (CRP ≥ 40 mg/l) showed a higher one year mortality of 33 % and 40 % compared to 16 % in patients with no (CRP < 10 mg/l) inflammatory response (p = 0.002). Multiple logistic regression analysis identified CRP (OR 1.01, 95 % CI 1.00-1.02; p = 0.007), but not 25(OH)D (OR 0.97, 95 % CI 0.89-1.05; p = 0.425) as an independent predictor for one year mortality. 20 % of patients suffered in-hospital postoperative medical complications (i.e. pneumonia, thromboembolic events, etc.). 25(OH)D (OR 0.89, 95 % CI 0.81-0.97; p = 0.010), but not CRP (OR 1.01, 95 % CI 1.00-1.02; p = 0.139), was identified as an independent risk factor. CONCLUSION: In elderly patients with low-energy cervical hip fracture, 25(OH)D is independently associated with postoperative medical complications and CRP is an independent predictor of one year mortality.

Can improved quality of care explain the success of orthogeriatric units? A population-based cohort study.

BACKGROUND: admission to orthogeriatric units improves clinical outcomes for patients with hip fracture; however, little is known about the underlying mechanisms. OBJECTIVE: to compare quality of in-hospital care, 30-day mortality, time to surgery (TTS) and length of hospital stay (LOS) among patients with hip fracture admitted to orthogeriatric and ordinary orthopaedic units, respectively. DESIGN: population-based cohort study. MEASURES: using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 11,461 patients aged ≥65 years admitted with a hip fracture between 1 March 2010 and 30 November 2011. The patients were divided into two groups: (i) those treated at an orthogeriatric unit, where the geriatrician is an integrated part of the multidisciplinary team, and (ii) those treated at an ordinary orthopaedic unit, where geriatric or medical consultant service are available on request. Outcome measures were the quality of care as reflected by six process performance measures, 30-day mortality, the TTS and the LOS. Data were analysed using log-binomial, linear and logistic regression controlling for potential confounders. RESULTS: admittance to orthogeriatric units was associated with a higher chance for fulfilling five out of six process performance measures. Patients who were admitted to an orthogeriatric unit experienced a lower 30-day mortality (adjusted odds ratio (aOR) 0.69; 95% CI 0.54-0.88), whereas the LOS (adjusted relative time (aRT) of 1.18; 95% CI 0.92-1.52) and the TTS (aRT 1.06; 95% CI 0.89-1.26) were similar. CONCLUSIONS: admittance to an orthogeriatric unit was associated with improved quality of care and lower 30-day mortality among patients with hip fracture.

Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year.

Hip fractures are a major cause of hospital stay among the elderly, and result in increased disability and mortality. In this study from 1 April 2003 to 31 March 2004, the influence of optimised treatment of hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year were investigated. Comparisons were made between the first 210 patients in the period and the last 210 patients, who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24h, was not associated with reduced mortality, but was significantly associated with reduced length of stay (p<0.001). Significantly more cases of osteosynthesis for femoral neck fracture were reoperated compared with all other types of surgery (p<0.001) when reoperations with extraction of the hook pins in healed fractures were excluded. Mortality was significantly higher among men than women at 4 (p=0.025) and 12 (p=0.001) months after fracture and among medically fit patients with administrative delay to surgery compared with patients with no delay (p<0.001).