Prediction of long-term mortality following hip fracture surgery: evaluation of three risk models.

INTRODUCTION: Several prognostic models have been developed for mortality in hip fracture patients, but their accuracy for long-term prediction is unclear. This study evaluates the performance of three models assessing 30-day, 1-year and 8-year mortality after hip fracture surgery: the Nottingham Hip Fracture Score (NHFS), the model developed by Holt et al. and the Hip fracture Estimator of Mortality Amsterdam (HEMA). MATERIALS AND METHODS: Patients admitted with a fractured hip between January 2012 and June 2013 were included in this retrospective cohort study. Relevant variables used by the three models were collected, as were mortality data. Predictive performance was assessed in terms of discrimination with the area under the receiver operating characteristic curve and calibration with the Hosmer-Lemeshow goodness-of-fit test. Clinical usefulness was evaluated by determining risk groups for each model, comparing differences in mortality using Kaplan-Meier curves, and by assessing positive and negative predictive values. RESULTS: A total of 344 patients were included for analysis. Observed mortality rates were 6.1% after 30 days, 19.1% after 1 year and 68.6% after 8 years. The NHFS and the model by Holt et al. demonstrated good to excellent discrimination and adequate calibration for both short- and long-term mortality prediction, with similar clinical usefulness measures. The HEMA demonstrated inferior prediction of 30-day and 8-year mortality, with worse discriminative abilities and a significant lack of fit. CONCLUSIONS: The NHFS and the model by Holt et al. allowed for accurate identification of low- and high-risk patients for both short- and long-term mortality after a fracture of the hip. The HEMA performed poorly. When considering predictive performance and ease of use, the NHFS seems most suitable for implementation in daily clinical practice.

Mortality Prediction in Hip Fracture Patients: Physician Assessment Versus Prognostic Models.

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.

Predicting Early Mortality After Hip Fracture Surgery: The Hip Fracture Estimator of Mortality Amsterdam.

OBJECTIVES: Early mortality after hip fracture surgery is high and preoperative risk assessment for the individual patient is challenging. A risk model could identify patients in need of more intensive perioperative care, provide insight in the prognosis, and allow for risk adjustment in audits. This study aimed to develop and validate a risk prediction model for 30-day mortality after hip fracture surgery: the Hip fracture Estimator of Mortality Amsterdam (HEMA). METHODS: Data on 1050 consecutive patients undergoing hip fracture surgery between 2004 and 2010 were retrospectively collected and randomly split into a development cohort (746 patients) and validation cohort (304 patients). Logistic regression analysis was performed in the development cohort to determine risk factors for the HEMA. Discrimination and calibration were assessed in both cohorts using the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, and by stratification into low-, medium- and high-risk groups. RESULTS: Nine predictors for 30-day mortality were identified and used in the final model: age ≥85 years, in-hospital fracture, signs of malnutrition, myocardial infarction, congestive heart failure, current pneumonia, renal failure, malignancy, and serum urea >9 mmol/L. The HEMA showed good discrimination in the development cohort (AUC = 0.81) and the validation cohort (AUC = 0.79). The Hosmer-Lemeshow test indicated no lack of fit in either cohort (P > 0.05). CONCLUSIONS: The HEMA is based on preoperative variables and can be used to predict the risk of 30-day mortality after hip fracture surgery for the individual patient. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The weekend effect for hip fracture surgery.

INTRODUCTION: Increased mortality rates have been reported for emergency admissions during weekends and outside office hours. Research on the weekend effect in hip fracture patients is however limited and demonstrates conflicting results. The aim of this study was to determine the effect of weekend admission and weekend surgery on 30-day and 1-year mortality following hip fracture surgery. PATIENTS AND METHODS: All patients who underwent hip fracture surgery in our hospital between 2004 and 2015 were included in this retrospective study. Patient characteristics including age, gender, fracture type, American Society of Anesthesiologists (ASA) score, Nottingham Hip Fracture Score (NHFS), Charlson Comorbidity Index (CCI) and length of stay were collected. Information on admission and surgery date and time of day was recorded, as were in-hospital, 30-day and 1-year mortality. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day and 1-year mortality. RESULTS: A total of 1803 patients were included, 546 patients (30.3%) were admitted during the weekend. Patient characteristics did not differ between weekday and weekend admissions. Surgical delay was less frequent in patients undergoing weekend surgery. Multivariable analysis demonstrated that older age, higher ASA score, higher NHFS and increased surgical delay were independently associated with 30-day mortality. One-year mortality was associated with age, gender, ASA score, CCI and surgical delay. Weekend admission and weekend surgery were not associated with increased 30-day or 1-year mortality. CONCLUSIONS: There was no weekend effect for hip fracture patients in our study. These results indicate an adequate level of perioperative care outside weekday office hours within our health care system.

Predicting postoperative complications after bariatric surgery: the Bariatric Surgery Index for Complications, BASIC.

BACKGROUND: Around 20% of bariatric surgery patients develop a short- or long-term complication. OBJECTIVE: Aim of this study was to develop a risk model predicting complications: the Bariatric Surgery Index for Complications (BASIC). SETTING: The Obesity Center Amsterdam, located in a large teaching hospital, in Amsterdam, The Netherlands. METHODS: A prospective consecutive database including patients operated between November 2007 and February 2015 was used. For the BASIC, analysis according to the TRIPOD statement was performed to identify risk factors for complications. Class I included patients with zero to one risk factor, class II patients with two risk factors, and class III patients with three or more risk factors. RESULTS: Of 1709 analyzed patients, mean age was 45 years (±SD 10.7), 1393 (81.5%) were female; mean body mass index was 44.5 kg/m2 (6.8). Overall, 271 (15.9%) patients developed a complication of which 197 (72.5%) occurred within 30 days. Predictors in multivariable analysis were use of anticoagulants (odd's ratio (OR) 1.5); chronic obstructive pulmonary disease (OR 2.3); dyslipidemia (OR 1.4); gender (OR 1.4); psychiatric history (OR 1.3); and revisional surgery (OR 1.5). In class I, 13.5% (181 out of 1338) experienced complications, in class II 58 (21.6%) of the 269 patients and in class III 32 (31.4%) of the 102 patients, respectively. There was a significant difference (p < 0.001) in both overall and 30 day complications. CONCLUSION: The BASIC uses six preoperative variables to classify patients in a low-, intermediate-, or high-risk group for postoperative complications after bariatric surgery.

Do-not-resuscitate orders and early mortality in hip fracture patients.

Background: factors affecting mortality after hip fracture surgery have been studied extensively. It has been suggested that do-not-resuscitate (DNR) orders are associated with higher mortality in surgical patients due to less aggressive treatment. However, the effect of DNR orders on mortality in hip fracture patients is unknown. The objective of this study was to investigate the effect of DNR orders on early mortality after hip fracture surgery. Methods: all patients undergoing hip fracture surgery between 2004 and 2015 were included in this retrospective study. Patient characteristics such as age, comorbidities and fracture type were collected, as were resuscitation preferences. Multivariable logistic regression analysis was performed to identify independent risk factors for early mortality. Results: a total of 1,803 patients were analysed, of which 823 (45.6%) had DNR orders. DNR patients were older, more often female, had lower haemoglobin levels and more comorbidities when compared with non-DNR patients. The unadjusted effect of DNR orders on mortality was high (OR: 2.39; P < 0.001). Multivariable analysis demonstrated that increased age, male gender, higher American Society of Anesthesiologists score, low admission haemoglobin, living in an institution, high Charlson Comorbidity Index and delay to surgery were associated with increased early mortality after hip fracture surgery. There was no independent effect of DNR orders on mortality after adjustment for these variables (P = 0.735). Conclusions: DNR patients have higher mortality rates due to poor health status. Resuscitation preferences on their own are not associated with early mortality after hip fracture surgery.

Predicting 30-day mortality following hip fracture surgery: evaluation of six risk prediction models.

INTRODUCTION: While predictors for mortality after hip fracture surgery have been widely studied, research regarding risk prediction models is limited. Risk models can predict mortality for individual patients, provide insight in prognosis, and be valuable in surgical audits. Existing models have not been validated independently. The purpose of this study is to evaluate the performance of existing risk models for predicting 30-day mortality following hip fracture surgery. PATIENTS AND METHODS: In this retrospective study, all consecutive hip fracture patients admitted between 2004 and 2010 were included. Predicted mortality was calculated for individual patients and compared to the observed outcome. The discriminative performance of the models was assessed using the area under the receiver operating characteristic curve (AUC). Calibration was analysed with the Hosmer-Lemeshow goodness-of-fit test. RESULTS: A literature search yielded six risk prediction models: the Charlson Comorbidity Index (CCI), Orthopaedic Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (O-POSSUM), Estimation of Physiologic Ability and Surgical Stress (E-PASS), a risk model by Jiang et al., the Nottingham Hip Fracture Score (NHFS), and a model by Holt et al. The latter three models were specifically designed for the hip fracture population. All models except the O-POSSUM achieved an AUC greater than 0.70, demonstrating acceptable discriminative power. The score by Jiang et al. performed best with an AUC of 0.78, this was however not significantly different from the NHFS (0.77) or the model by Holt et al. (0.76). When applying the Hosmer-Lemeshow goodness-of-fit test, the model by Holt et al., the NHFS and the model by Jiang et al. showed a significant lack of fit (p<0.05). The CCI, O-POSSUM and E-PASS did not demonstrate lack of calibration. DISCUSSION: None of the existing models yielded excellent discrimination (AUC>0.80). The best discrimination was demonstrated by the models designed for the hip fracture population, however, they had a lack of fit. The NHFS shows most promising results, with reasonable discrimination and extensive validation in earlier studies. Additional research is needed to examine recalibration and to determine the best risk model for predicting early mortality following hip fracture surgery.

Cyst-like schwannoma on the eyelid margin.

Schwannomas are benign tumors originating from Schwann cells. We describe a rare case of solitary schwannoma on the eyelid margin. To our knowledge, this is the first clinical report of such a lesion on the eyelid margin, confirmed by both extensive immunohistochemical analysis and its distinctive morphology. Although schwannomas seldom undergo malignant change, they should be considered in the differential diagnosis of palpebral lesions.