Usefulness of a national hip fracture registry to evaluate the profile of patients in whom antiosteoporotic treatment is prescribed following hospital discharge.

This study was carried out to describe the profile of prescription of antiosteoporotic treatment at discharge after a hip fracture in the Spanish National Hip Fracture Registry. Prescription rates among hospitals ranged from 0 to 94% of patients discharged. The prescription rate was higher among patients with better cognitive and functional baseline status. PURPOSE: National hip fracture registries are useful for assessing current care processes. The goals of this study were as follows: first, to know the rate of antiosteoporotic prescription at discharge among hip fracture patients in hospitals participating in the Spanish National Hip Fracture Registry (RNFC); second, to compare the differences between treated and non-treated patients; third, to analyze patients' characteristics associated with antiosteoporotic prescription at discharge; and fourth, to evaluate whether there were differences in the profile of patients discharged from hospitals with high and low prescription rates. METHOD: Patients discharged after a fragility hip fracture in 2017 and participating in the RNFC were included. Demographic variables, cognitive and functional status, prefracture osteoporosis treatment, fracture type, anesthetic risk, hospital volume, and antiosteoporotic prescription at discharge were analyzed. Given that patients were clustered within hospitals, intraclass correlation was calculated and generalized estimating equations were fitted. RESULTS: A total of 6701 patients from 54 hospitals were included. Antiosteoporotic prescription at discharge was prescribed to 36.5% (CI95% 35.8-37.2%), with a wide inter-hospital variability (range 0-94%). The intraclass correlation due of clustering of patients within hospitals was 47.9%. Antiosteoporotic prescription was more likely in patients who were younger, lived at home, previously treated for osteoporosis, had better baseline functional and cognitive status, lower anesthetic risk, and were discharged from high-volume hospitals, all with p < 0.001. The general profile of patients discharged from hospitals with high and low rate of prescription was similar. CONCLUSIONS: There is a wide variability between hospitals regarding antiosteoporotic prescription after hip fracture. This is more likely to be initiated in patients with better clinical, functional, and mental status and in those discharged from hospitals with larger volumes of patients. These results offer insights regarding the selection of patients receiving secondary prevention and raises questions on who and how many should be treated.

Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries.

Hip fracture registries have helped improve quality of care and reduce variability, and several audits exist worldwide. The results of the Spanish National Hip Fracture Registry are presented and compared with 13 other national registries, highlighting similarities and differences to define areas of improvement, particularly surgical delay and early mobilization. INTRODUCTION: Hip fracture audits have been useful for monitoring current practice and defining areas in need of improvement. Most established registries are from Northern Europe. We present the results from the first annual report of the Spanish Hip Fracture Registry (RNFC) and compare them with other publically available audit reports. METHOD: Comparison of the results from Spain with the most recent reports from another ten established hip fracture registries highlights the differences in audit characteristics, casemix, management, and outcomes. RESULTS: Of the patients treated in 54 hospitals, 7.208 were included in the registry between January and October 2017. Compared with other registries, the RNFC included patients ≥ 75 years old; in general, they were older, more likely to be female, had a worse prefracture ambulation status, and were more likely to have extracapsular fractures. A larger proportion was treated with intramedullary nails than in other countries, and spinal anesthesia was most commonly used. With a mean of 75.7 h, Spain had by far the longest surgical delay, and the lowest proportion of patients mobilized on the first postoperative day (58.5%). Consequently, development of pressure ulcers was high, but length of stay, mortality, and discharge to home remained in the range of other audits. CONCLUSIONS: National hip fracture registries have proved effective in changing clinical practice and our understanding of patients with this condition. Such registries tend to be based on an internationally recognized common dataset which would make comparisons between national registries possible, but variations such as age inclusion criteria and follow-up are becoming evident across the world. This variation should be avoided if we are to maximize the comparability of registry results and help different countries learn from each other's practice. The results reported in the Spanish RNFC, compared with those of other countries, highlight the differences between countries and detect areas of improvement, particularly surgical delay and early mobilization.

Baseline and 1-year follow-up differences between hip-fracture patients admitted from nursing homes and the community. A cohort study on 509 consecutive patients (FONDA Cohort).

OBJECTIVE: To determine the clinical and functional differences at hospital admission and at 1 year after a hip fracture (HF) in nursing homes (NH) and community-dwelling (CD) patients. METHODS: All patients with HF admitted to the orthogeriatric unit at a university hospital between January 2013 and February 2014 were prospectively included. Clinical and functional variables, and mortality were recorded during the hospital admission. The patients were contacted by telephone at 1 year to determine their vital condition and functional status. RESULTS: A total of 509 patients were included, 116 (22.8%) of whom came from NH. Compared with the CD patients, the NH patients had higher surgical risk (ASA ≥3: 83.6% vs. 66.4%, P<.001), poorer theoretical vital prognosis (Nottingham Profile ≥5: 98.3% vs. 56.6%, P<.001), higher rate of previous functional status (median Barthel index: 55 [IQR, 36-80] vs. 90 [IQR, 75-100], P<.001), poorer mental status (Pfeiffer's SPMSQ>2: 74.1% vs. 40.2%, P<.001), and a higher rate of sarcopenia (24.3% vs. 15.2%, P<.05). There were no differences in in-hospital or at 1-year mortality. At 1 year, NH patients recovered their previous walking capacity at a lower rate (38.5% vs. 56.2%, P<.001). CONCLUSIONS: Among the patients with HF treated in an orthogeriatric unit, NH patients had higher, surgical risk, functional and mental impairment, and a higher rate of sarcopenia than CD patients. At 1 year of follow-up, NH patients did not have higher mortality, but they recovered their previous capacity for walking less frequently.

Spanish National Hip Fracture Registry (SNHFR): a description of its objectives, methodology and implementation.

OBJECTIVE: To ascertain the current situation and clinical variability of the provision of care for Hip Fracture (HF) in Spain and the factors related to it by using a National Registry (NHFR) with high patient numbers and territorial representation NHFR, and to compare results on a national and international level and propose standards and criteria to improve healthcare quality. DESIGN: Continuous registry for at least three years of a representative sample of patients admitted to Spanish hospitals due to HF using the Minimum Common Dataset - international Fragility Fracture Network (FFN) MCD, adapted for Spanish. STUDY SCOPE AND SUBJECTS: all patients over the age of 74 years who are hospitalized with a diagnosis of a fragility HF at the participating hospitals distributed throughout the Spanish territory. Initially 48 hospitals are included, and we expect to incorporate the highest number of sites possible. RESULTS: It is expected to ascertain the current situation of provision of care for HF in Spain. Each hospital will be offered information regarding their results and their situation compared to the rest. The results from national hospitals will be compared to others included in the registry and to hospitals abroad, which use the same database. Variability will be studied, care standards will be established, and objectives will be proposed for the continuous improvement of the care process of this condition.

[Fragile hip fracture in Mexico: Where are we today? Where do we want to go?] / Fractura de cadera por fragilidad en México: ¿En dónde estamos hoy? ¿Hacia dónde queremos ir?

INTRODUCTION: Hip fracture is considered the most serious consequence of falls and osteoporosis. 18% of women will suffer one and 25% die in the first year. Only 73% of survivors will walk as they did previously. We know little about the assistance and evolution of it in Mexico. Our goal was to review the current state of Mexican literature on hip fracture, compare Mexican studies with each other and with quality indicators. METHODS: We conducted a search of Mexican articles published between 2000-2017 with the key words: hip fracture, elderly, Mexico and hip fracture (in English) in the databases PubMed, EBSCO and Bibliomed. RESULTS: Twenty-one articles were included. No clinical trials, multidisciplinary unit reports, records, or meta-analyses were found. The average age was 76.9 years and 67.2% were women. No papers were found to report quality indicators. Comorbidity is reported little. The most common complications of hip fractures were delirium, pneumonia and pressure ulcers. Mortality in the acute phase was 0.97 to 12.5%. Special units were not reported. The cost of care oscillated between 1,261 and 13,641 USD. CONCLUSIONS: The scientific information on hip fractures in Mexico is sparse, heterogeneous and does not allow for conclusive results. Increasing the amount and quality of research in hip fractures in Mexico is required. It would also be advisable to disseminate the usefulness of multidisciplinary teams and registry of hip fractures, which would help to improve attention.

INTRODUCCIÓN: La fractura de cadera (FC) se considera la consecuencia más grave de las caídas y la osteoporosis. Dieciocho por ciento de las mujeres sufrirán una FC y 25% muere en el primer año. Sólo 73% de los supervivientes caminará como lo hacía previamente. Conocemos poco de la asistencia y evolución de la FC en México. OBJETIVO: Revisar el estado actual de la literatura mexicana sobre FC, comparar estudios mexicanos entre sí y con los indicadores de calidad. METODOLOGÍA: Se realizó una búsqueda de artículos mexicanos publicados entre 2000 y 2017 con las palabras clave: fractura de cadera, ancianos, México y hip fracture en las bases de datos PubMed, EBSCO y Bibliomed. RESULTADOS: Se incluyeron 22 artículos. No se encontraron ensayos clínicos, informes de unidades multidisciplinarias, registros, ni metaanálisis. La media de edad fue de 76.9 años y 67.2% fueron mujeres. No se encontraron trabajos que reportaran indicadores de calidad. La comorbilidad se describe poco. Las complicaciones más frecuentes de la FC fueron delirium, neumonía y úlceras por presión. La mortalidad en la fase aguda fue de 0.97 a 12.5%. No se reportaron unidades ortogeriátricas. El costo de atención osciló entre 1,261 y 13,641 dólares estadounidenses (USD). CONCLUSIONES: La información científica sobre FC en México es escasa, heterogénea y no permite obtener resultados concluyentes. Se requiere aumentar la cantidad y la calidad de la investigación en FC en México. Sería también conveniente difundir la utilidad de los equipos multidisciplinarios y registros de FC, lo que contribuiría a mejorar la atención.

Prevalence of malnutrition in a cohort of 509 patients with acute hip fracture: the importance of a comprehensive assessment.

Backgrounds/objectives:Malnutrition is very common in acute hip fracture (HF) patients. Studies differ widely in their findings, with reported prevalences between 31 and 88% mainly because of small sample sizes and the use of different criteria. The aim of this study was to learn the prevalence of malnutrition in a large cohort of HF patients in an comprehensive way that includes the frequency of protein-energy malnutrition, vitamin D deficiency and sarcopenia. SUBJECTS/METHODS: A 1-year consecutive sample of patients admitted with fragility HF in a 1300-bed public University Hospital, who were assessed within the first 72 h of admission. Clinical, functional, cognitive and laboratory variables were included. Energy malnutrition (body mass index (BMI) <22 kg/m2), protein malnutrition (serum total protein <6.5 g/dl or albumin <3.5 g/dl), vitamin D deficiency (serum 25-OH-vitamin D <30 ng/dl) and sarcopenia (low muscle mass plus low grip strength) were considered. RESULTS: Five hundred nine HF patients were included. The mean age was 85.6±6.9 years and 79.2% were women. Ninety-nine (20.1%) patients had a BMI <22 kg/m2. Four hundred nine patients (81.2%) had protein malnutrition. Eighty-seven (17.1%) patients had both energy and protein malnutrition. Serum vitamin D was <30 ng/ml in 466 (93%) patients. The prevalence of sarcopenia was 17.1%. CONCLUSIONS: Protein malnutrition and vitamin D deficiency are the rule in acute HF patients. Energy malnutrition and sarcopenia are also common. A nutritional assessment in these patients should include these aspects together.

Hip fracture registries: utility, description, and comparison.

Hip fractures (HF) are prevalent and involve high morbidity and mortality so improving their management is important. HF registries are a good way to improve knowledge about this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs. INTRODUCTION: Hip fractures (HF) are a prevalent fragility fracture secondary to osteoporosis that involves high morbidity and mortality. They are low-impact fractures, resulting from a fall from a standing or sitting height. Despite numerous Clinical Practice Guidelines that establish uniform recommendations for their care, great variability persists regarding clinical and healthcare outcomes. Fracture registries can help detect deficits and establish measures to improve care. The objective of this work is to analyze the contents that a HF registry should have and to compare the characteristics of some national HF registries. METHODS: A literature search was conducted on several national hip fracture registries, and those that contain relevant information on the variables and their outcomes were selected. RESULTS: The selected HF registries were compared using the parameters they measure as well as the outcomes in the different countries. The variables collected in the majority of the databases and those that give useful information are as follows: sociodemographic variables (age, sex, place of residence), clinical variables (function before and after HF, anesthesia risk as measured by the ASA score, type of fracture, type of surgery and anesthesia, and in-hospital and 1-month mortality), and healthcare variables (pre-operative and overall stay, presence of collaboration with orthogeriatrics or with any clinician in addition to the surgeon, secondary prevention of new fractures by assessing the fall risk, and need for osteoporosis treatment). CONCLUSION: The recording of HF cases in different countries improves knowledge about handling this condition and its quality of care, while at the same time reducing clinical variability, optimizing efficiency, improving outcomes, and reducing costs. The debate on the variables that should be recorded is timely, such as organizing how to collect each measurement, and even trying to unify the national and international registries or using a current proposal such as the one from the Fragility Fracture Network.

Parathyroid hormone response to two levels of vitamin D deficiency is associated with high risk of medical problems during hospitalization in patients with hip fracture.

BACKGROUND: Vitamin D and the parathyroid hormone (PTH) response play an important role in hip fracture patients. This study was carried out to determine the factors associated with the PTH response to different levels of vitamin D deficiency during hospitalization. METHODS: This was a cross-sectional study of patients over 64 years of age admitted with an acute fragility hip fracture between March 1st 2009 and November 30th 2012. Demographic, clinical, functional, and cognitive function were evaluated at admission and during hospitalization. Levels of 25-hydroxyvitamin D (25-OHD) and PTH were analyzed. Two 25-OHD cut-off points were considered, <12 ng/ml and 12-20 ng/ml. Multivariate logistic regression analysis was used. RESULTS: Mean age of the 607 patients included was 84.7 years (SD 7.10), and 81.9 % were women. The mean 25-OHD level in the total sample was 13.2 (SD 11.1) ng/ml. Levels of 25-OHD <12 ng/ml were present in 347 patients (57.2 %), of whom 158 (45.5 %) had secondary hyperparathyroidism (SHPT) (PTH >65 pg/ml). 25-OHD levels of 12-20 ng/ml were present in 168 (27.7 %) patients, of whom 47 (28 %) had SHPT. Following logistic regression, SHPT was associated in both groups (25-OHD <12 and 12-20 ng/ml) with a greater number of medical problems during hospitalization. In the 25-OHD group <12 ng/ml, SHPT was also associated with poorer glomerular filtration rates. CONCLUSION: The PTH response to vitamin D deficiency in hip fracture patients may be a marker for patients with higher risk of developing multiple medical problems, both when considering severe (<12 ng/ml) and moderate (12-20 ng/ml) vitamin D deficiency.

Walking speed and high blood pressure mortality risk in a Spanish elderly population.

This study analyzed the relationship between blood pressure and all-cause mortality according to objectively measured walking speed in a Mediterranean population-based sample of older persons. We used data from the longitudinal 'Peñagrande' Cohort Study, initiated in 2008 in a sex- and age-stratified random sample of 1250 people aged ⩾65 years living in Madrid (Spain). A total of 814 individuals participated in the first study wave. The average of two standardized blood pressure readings was used. Walking speed was measured over a 3-m walk and classified as faster (⩾0.8 m s(-1)) or slower. A total of 314 individuals were slower walkers, 475 were faster walkers and 25 did not complete the walk test. Cox proportional hazards models stratified by walking speed were used to assess the association between blood pressure and all-cause death. Non-linear relationship between BP and mortality was explored by a restricted cubic spline analysis. There were 171 deaths from study entry through 31 March 2013. Systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mmHg were associated with higher mortality than blood pressure values above 140 and 90 mm Hg, respectively, but this association reached statistical significance only for systolic blood pressure and only in the slower walkers. In conclusion, systolic blood pressure levels <140 mm Hg were found associated with higher risk of total mortality among slower walkers in an old Spaniard population cohort.

A new hierarchical classification for prognosis of hip fracture after 2 years' follow-up.

OBJECTIVES: To examine the prognostic value of different profiles of hip fracture patients for recovery of pre-fracture functional level and for post-fracture mortality. DESIGN: Observational, longitudinal study. SETTING: University hospital. PARTICIPANTS: Five hundred and eight patients who received surgery for hip fracture and were followed for 24 months post-fracture. MEASUMENTS: Patients were assessed according to age, number of independent activities of daily living (ADLs) and dementia. The probability of recovery of previous ambulation level and mortality was established at 3, 6, 12 and 24 months post-fracture. Patients were first classified according to the seven different profiles previously established by Penrod. A new patient classification system was then created using different patient groups: persons aged 75 or older were first classified based on the number of independent ADLs they could perform (4, 3-2 and 1-0) and were then subdivided according to age (75-84 years and >84 years) and presence of dementia. RESULTS: Mean age was 84.5 (SD 6.3) years. Almost all (90.6%) patients walked independently before the fracture. At 24 months' follow-up, the probability of recovery to previous level of ambulation was 73.6%. The new classification into seven groups had higher prognostic value than Penrod's system. Patients under 75 had 95.1% probability of functional recovery and 9.6% of dying. At the other extreme, those over 84 years with 0-1 independent activities of daily living and dementia had 23.9% probability of recovery and 71.4% of dying. CONCLUSION: Hip fracture patients can be classified into homogeneous groups with different prognostic profiles based on pre-fracture characteristics. This new classification improves Penrod's previous system by establishing groups of patients hierarchically ordered by the probability of recovery and mortality at 3, 6, 12 and 24 months post-fracture.

Activities of daily living after hip fracture: profile and rate of recovery during 2 years of follow-up.

SUMMARY: In this study 509 hip fracture patients were followed-up during 24 months measuring their recuperation in activities of daily living. The different activities measured had both different profile and probability of recovery. INTRODUCTION: Recovery of pre-fracture functional level is a goal of hip fracture treatment. The objective of this study was to measure recovery of previous functional level for ambulation and for the activities of daily living during the 24 months after osteoporotic hip fracture. METHODS: This is a longitudinal prospective study of the patients admitted to the orthopaedics department of a university hospital for hip fracture and followed up by a geriatrician during three years (2003-2005). Demographic, clinical, functional and treatment data were collected during hospitalisation. Telephone follow-up was made at 3, 6, 12 and 24 months. Data were analysed by survival analysis applying the Kaplan-Meier estimator. RESULTS: Five hundred and nine patients were included. The mean age was 84.5 (SD 6.3) years. The activities with lower probability of recovery to the previous level at 24 months were climbing stairs, chair/bed transfers, ambulation, dressing, bathing and use of toilet (between 67.5% and 76% recovery). The activities with higher probability of recovery were grooming, feeding and bladder and bowel control (between 86.3% and 95.4%). Recovery of previous performance level for ambulation, chair/bed transfers, use of toilet, feeding, grooming and bladder control occurred primarily during the first 6 months, whereas recovery of bathing, dressing and climbing stairs occurred mainly in the first 12 months after the fracture. CONCLUSIONS: The activities with lower likelihood of recovery were ambulation, chair/bed transfers, climbing stairs, use of toilet, bathing and dressing. Time of recovery varied by activity; bathing, dressing and climbing stairs were the activities with the longest recovery time.

Fractura osteoporótica de cadera. Factores predictivos de recuperación funcional a corto y largo plazo / Osteoporotic hip fracture. Predictive factors of short- and long-term functional recovery

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Interconsulta geriátrica en el Servicio de Traumatología. Beneficios asistenciales / Geriatric consultations by the orthopaedics department. Health care benefits

Objetivo: Describir la actividad de un equipo de valoración geriátrica (EVG) en el servicio de traumatología en un hospital general universitario durante sus primeros años de funcionamiento. Evaluar la influencia sobre parámetros asistenciales de la interconsulta a geriatría en ancianos ingresados en dicho servicio. Material y método: Se revisaron todas las interconsultas realizadas al EVG a lo largo de tres años (1995-1997) de pacientes mayores de 65 años ingresados en traumatología. Los tipos de interconsulta se clasificaron en: a) valoración geriátrica puntual o el traslado del paciente a otro hospital y b) valoración y seguimiento clínico y tratamiento del paciente durante la hospitalización. En todos los pacientes se realizó una valoración geriátrica integral estructurada. Resultados: Se observó un cambio en el tipo de consultas solicitadas a lo largo del tiempo. Las peticiones de traslado de pacientes se redujeron de 76 por ciento en 1995 al 23 por ciento en 1997 y las de seguimiento clínico aumentaron del 24 por ciento al 77 por ciento. Los pacientes seguidos clínicamente fueron 2 años mayores de edad como media, pero tuvieron una estancia media 8 días menor (20,4, vs 28,8 días; p < 0,01), sin aumentar la necesidad de cuidados institucionales tras el alta. La precocidad de la interconsulta a geriatría fue la variable independiente, de entre las estudiadas, que más se asoció a una estancia hospitalaria menor. Conclusión: El beneficio que aporta la geriatría en pacientes ingresados en traumatología es mayor cuanto más precoz e intensa es la acción directa del geriatra sobre el paciente. (AU)

Revista Española de Geriatría y Gerontología. Año 2000 / Spanish Journal of Geriatrics and Gerontology. Year 2000

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