The process of hip fracture management before and during the COVID-19 pandemic in Iran.

BACKGROUND: The COVID-19 pandemic affected the control of many chronic conditions, including hip fractures, worldwide. This study was to examine the impact of the COVID-19 pandemic on the management of hip fractures in a referral orthopedic hospital in Iran. By understanding how the pandemic has influenced the care of hip fracture patients, we can gain valuable insights into the challenges, adaptations, and potential improvements in orthopedic healthcare during such public health crises. METHODS: Data was collected on hip fracture patients aged 50 and above who were admitted to the hospital before and during the pandemic. The number of admissions and operations, length of hospital stay, and time from admission to surgery were recorded from the hospital information system (HIS) and compared between the two periods. RESULTS: The median number of admitted hip fracture patients per month increased slightly during the pandemic (11%), although this increase was not statistically significant (p = 0.124). After adjusting for potential confounders, the mean length of hospital stay was significantly lower during the pandemic period, indicating that patients were discharged sooner (p = 0.019) and the time from admission to surgery was shorter during the pandemic (p = 0.004). Although the increase in the number of hip fracture surgeries per month during the pandemic was not statistically significant (P = 0.132), a higher percentage of patients underwent surgery during the pandemic compared to before (84.8% VS. 79.4%). CONCLUSION: The study suggests that the COVID-19 pandemic did not have a negative impact on hip fracture management in the investigated orthopedic hospital in Iran. further research is needed to explore the effects of the pandemic on other aspects of healthcare services, particularly in general hospitals.

Age-dependent FRAX-based assessment and intervention thresholds for therapeutic decision making in osteoporosis in the Malaysian population.

Fracture risk stratification is crucial in countries with limited access to bone density measurement. 24.8% women were in the high-risk category while 30.4% were in the low-risk category. In the intermediate risk group, after recalculation of fracture risk with bone density, 38.3% required treatment. In more than half, treatment decisions can be made without bone density. PURPOSE: We aimed to examine the role of age-dependent intervention thresholds (ITs) applied to the Fracture Risk Assessment (FRAX) tool in therapeutic decision making for osteoporosis in the Malaysian population. METHODS: Data were collated from 1380 treatment-naïve postmenopausal women aged 40-85 years who underwent bone mineral density (BMD) measurements for clinical reasons. Age-dependent ITs, for both major osteoporotic fracture (MOF) and hip fracture (HF), were calculated considering a woman with a BMI of 25 kg/m2, aged between 40 and 85years, with a prior fragility fracture, sans other clinical risk factors. Those with fracture probabilities equal to or above upper assessment thresholds (UATs) were considered to have high fracture risk. Those below the lower assessment thresholds (LATs) were considered to have low fracture risk. RESULTS: The ITs of MOF and HF ranged from 0.7 to 18% and 0.2 to 8%, between 40 and 85years. The LATs of MOF ranged from 0.3 to 11%, while those of HF ranged from 0.1 to 5.2%. The UATs of MOF and HF were 0.8 to 21.6% and 0.2 to 9.6%, respectively. In this study, 24.8% women were in the high-risk category while 30.4% were in the low-risk category. Of the 44.8% (n=618) in the intermediate risk group, after recalculation of fracture risk with BMD input, 38.3% (237/618) were above the ITs while the rest (n=381, 61.7%) were below the ITs. Judged by the Youden Index, 11.5% MOF probability which was associated with a sensitivity of 0.62 and specificity of 0.83 and 4.0% HF probability associated with a sensitivity of 0.63 and a specificity 0.82 were found to be the most appropriate fixed ITs in this analysis. CONCLUSION: Less than half of the study population (44.8%) required BMD for osteoporosis management when age-specific assessment thresholds were applied. Therefore, in more than half, therapeutic decisions can be made without BMD based on these assessment thresholds.

Why is hospital discharge so difficult? Reconsidering patient trajectories in theory and practice: Insights from an ethnographic study of transitions in hip fracture care.

This paper combines translational mobilisation theory and assemblage thinking to elaborate the patient trajectory concept. Deploying ethnographic research on transitions in hip fracture care in Wales (2014-2016), it describes and explains the structures and logics that condition transition interfaces, how transition infrastructures enact patients and with what effects. Comparative analysis of transition in three distinctive assemblages offers new insights into the challenges of hospital discharge and opportunities for research and improvement.

Model of multidisciplinary teamwork in hip fracture care: a qualitative interview study.

OBJECTIVES: Hip fractures are common injuries in older age with high mortality requiring multidisciplinary clinical care. Despite guidance, there is considerable variation in hip fracture services and patient outcomes; furthermore, little is known about how successful multidisciplinary working can be enabled. This study aimed to characterise professionals' views about the core components of multidisciplinary teamwork in hip fracture care. DESIGN: The study comprised qualitative interviews with healthcare professionals delivering hip fracture care. Interviews were audio recorded, transcribed and analysed abductively: material was coded inductively and grouped into higher level concepts informed by theories and frameworks relating to teamwork. SETTING: Four hospitals in England. PARTICIPANTS: Participants were 40 healthcare professionals including orthopaedic surgeons, orthogeriatricians, physiotherapists and service managers. RESULTS: Results identified four components of successful multidisciplinary teamwork: (1) defined roles and responsibilities, (2) information transfer processes, (3) shared goals and (4) collaborative leadership. These were underpinned by a single concept: shared responsibility. Defined roles and responsibilities were promoted through formal care pathways, reinforced through induction and training with clear job plans outlining tasks. Information transfer processes facilitated timely information exchange to appropriate individuals. Well-defined common purpose was hindered by complex interdisciplinary professional relationships, particularly between orthogeriatric and orthopaedic staff, and encouraged through multidisciplinary team meetings and training. Clinical service leads were integral to bridging interdisciplinary boundaries. Mutual trust and respect were based on recognition of the value of different professional groups. Teamwork depended on formal clinical leads with facilitative and motivational roles, and on hospital leadership that created an environment supporting collaboration. Shared responsibility for patients was encouraged by joint orthopaedic and orthogeriatric care models. Staff shared responsibility by assisting colleagues when needed. CONCLUSIONS: Shared responsibility across the multidisciplinary team is fundamental to delivery of hip fracture care. Findings will inform development of clinical practice recommendations and training to build teamworking competencies.

Poor prognosis and risk factors of nonoperative treatment hip fracture patients with end-stage renal disease.

This study aims to summarize the prognosis and risk factors of nonoperative treatment patients of hip fracture with end-stage renal disease (ESRD). A total of 113 individuals of hip fracture with nonoperative treatment were retrospectively enrolled, 38 patients with ESRD were defined as the observation group, and the other 75 patients without ESRD were served as the control group. The difference in 30-day and 1-year mortality rate between the 2 groups was compared. The effects of risk factors on survival were estimated by the Cox proportional-hazards model. The survival difference was estimated by the method of Kaplan-Meier. In the subsequent subgroup analysis of the observation group, as before, the Cox proportional-hazards model and the Kaplan-Meier method were used. The 1-year mortality rate of the observation group was considerably higher than that of the control group, which was 86.84% and 32.0%, respectively (P < .005). For nonoperative treatment hip fracture subjects, ESRD, age ≥ 82, BMI (BMI) < 20, high Charlson Comorbidity Index (CCI) and low Barthel Index (BI) were associated with a low survival curve (P < .05). In the subsequent multivariable subgroup analyses, for nonoperative treatment hip fracture subjects with ESRD, high CCI and low BI were also the independent risk factors of mortality. For nonoperative treatment hip fracture subjects, ESRD, old age, low BMI, high CCI and low BI were the independent risk factors of mortality. For hip fracture subjects with ESRD, nonoperative treatment was associated with excess high 1-year mortality rate, especially for patients with high CCI and low BI.

Incidence, Quality of Care, and Mortality in Hip Fracture Patients in the Course of the COVID Pandemic: A Population-Based Cohort Study.

BACKGROUND: We assessed the incidence, quality of in-hospital care, and mortality for hip fracture (HF) patients in Denmark before and during the coronavirus disease (COVID) pandemic. METHODS: We obtained data from the Danish registries in the COVID period (March 11, 2020 to January 27, 2021, overall and in 5 periods) and compared it to a pre-COVID period (March 13, 2019 to March 10, 2020). We calculated the proportion of patients (%) that have fulfilled all the relevant quality indicators (a composite score of 100%) and adjusted hazard ratios (HR) with a 95% confidence interval (CI) for 30-day mortality. RESULTS: The incidence of HF was 5.7 per 1 000 person-years both in pre-COVID and COVID periods. About 35% of patients had a composite score of 100% in the COVID period compared to 28% in the pre-COVID period (proportion ratio 1.23 [95% CI: 1.17-1.30]). Fulfillment of all individual quality indicators was similar or higher in the COVID period. 30-day mortality was 9.5% in pre-COVID period, compared to 10.8% in the COVID period (HR 1.15 [95% CI: 1.02-1.30]). HRs varied from 1.07 (95% CI: 0.89-1.29) to 1.31 (95% CI: 1.06-1.62) in 5 COVID periods. In-hospital mortality was 4% in pre-COVID versus 4.4% in COVID period. CONCLUSIONS: The incidence of HF in Denmark remained unchanged. The quality of in-hospital care was higher in the COVID compared to pre-COVID period. Unfortunately, 30-day mortality was also higher, highlighting the importance of recognizing diversity of social networks, home support, and digital health intervention after discharge for outcome of HF patients.

Application of machine learning models on predicting the length of hospital stay in fragility fracture patients.

BACKGROUND: The rate of geriatric hip fracture in Hong Kong is increasing steadily and associated mortality in fragility fracture is high. Moreover, fragility fracture patients increase the pressure on hospital bed demand. Hence, this study aims to develop a predictive model on the length of hospital stay (LOS) of geriatric fragility fracture patients using machine learning (ML) techniques. METHODS: In this study, we use the basic information, such as gender, age, residence type, etc., and medical parameters of patients, such as the modified functional ambulation classification score (MFAC), elderly mobility scale (EMS), modified Barthel index (MBI) etc, to predict whether the length of stay would exceed 21 days or not. RESULTS: Our results are promising despite the relatively small sample size of 8000 data. We develop various models with three approaches, namely (1) regularizing gradient boosting frameworks, (2) custom-built artificial neural network and (3) Google's Wide & Deep Learning technique. Our best results resulted from our Wide & Deep model with an accuracy of 0.79, with a precision of 0.73, with an area under the receiver operating characteristic curve (AUC-ROC) of 0.84. Feature importance analysis indicates (1) the type of hospital the patient is admitted to, (2) the mental state of the patient and (3) the length of stay at the acute hospital all have a relatively strong impact on the length of stay at palliative care. CONCLUSIONS: Applying ML techniques to improve the quality and efficiency in the healthcare sector is becoming popular in Hong Kong and around the globe, but there has not yet been research related to fragility fracture. The integration of machine learning may be useful for health-care professionals to better identify fragility fracture patients at risk of prolonged hospital stays. These findings underline the usefulness of machine learning techniques in optimizing resource allocation by identifying high risk individuals and providing appropriate management to improve treatment outcome.

Evaluation of costs, osteoporosis treatment, and re-fractures in German collaborative orthogeriatric care after fragility fractures.

Orthogeriatric co-management (OGCM) may provide benefits for geriatric fragility fracture patients in terms of more frequent osteoporosis treatment and fewer re-fractures. Yet, we did not find higher costs in OGCM hospitals for re-fractures or antiosteoporotic medication for most fracture sites within 12 months, although antiosteoporotic medication was more often prescribed. PURPOSE: Evidence suggests benefits of orthogeriatric co-management (OGCM) for hip fracture patients. Yet, evidence for other fractures is rare. The aim of our study was to conduct an evaluation of economic and health outcomes after the German OGCM for geriatric fragility fracture patients. METHODS: This retrospective cohort study was based on German health and long-term care insurance data. Individuals were 80 years and older, sustained a fragility fracture in 2014-2018, and were treated in hospitals certified for OGCM (ATZ group), providing OGCM without certification (OGCM group) or usual care (control group). Healthcare costs from payer perspective, prescribed medications, and re-fractures were investigated within 6 and 12 months. We used weighted gamma and two-part models and applied entropy balancing to account for the lack of randomization. All analyses were stratified per fracture site. RESULTS: We observed 206,273 patients within 12-month follow-up, of whom 14,100 were treated in ATZ, 133,353 in OGCM, and 58,820 in other hospitals. Total average inpatient costs per patient were significantly higher in the OGCM and particularly ATZ group for all fracture sites, compared to control group. We did not find significant differences in costs for re-fractures or antiosteoporotic medication for most fracture sites, although antiosteoporotic medication was significantly more often observed in the OGCM and particularly ATZ group for hip, pelvic, and humerus fractures. CONCLUSION: The observed healthcare costs were higher in ATZ and OGCM hospitals within 12 months. Antiosteoporotic medication was prescribed more often in both groups for most fracture sites, although the corresponding medication costs did not increase.

A short length of hospital stay is not associated with risk of readmission among hip fracture patients - a Swedish national register-based cohort study.

BACKGROUND: Hospital length of stay (LoS) after a hip fracture likely mirrors health status; however, a too short hospitalization might increase the risk of readmission. In this national register-based study, we investigated the association between LoS after a hip fracture and the risk of readmissions. METHODS: 73,551 patients with a first hip fracture between 2012 and 2019 were followed for 4 months after discharge. LoS was categorized by cubic splines and the association with readmissions was analyzed with Cox regression models. RESULTS: The mean LoS was 11 ± 6 days and 25% of the study population had at least one readmission. Compared to the mean LoS of 9-12 days, there was a 18% decreased risk of readmission for LoS of 2-4 days (HR 0.82 [95% CI 0.77-0.87]) and 13% decrease for 5-8 days (HR 0.87 [95% CI 0.83-0.91]), when adjusting for sex, age, walking ability, ASA score, CCI, complications during hospitalization and living arrangements. For longer LoS, risk of readmission increased (13-23 days: HR 1.09 [95% CI 1.05-1.13] and 24 + days: HR 1.19 [95% CI 1.11-1.28]). The results were robust across sex, age, and living arrangements. The most common specific reasons for readmission were trauma/injury, cardiovascular and complications, and the proportions did not differ considerably between short and long LoS-categories. CONCLUSIONS: While a long LoS can be explained by the care need of the patient, a short LoS - compared to the average stay - does not increase the risk of readmission regardless of health status and hospital complications in a Swedish setting.

Cost-effectiveness analysis of the Geriatric Fracture Center (GFC) concept: a prospective multicentre cohort study.

INTRODUCTION: Geriatric Fracture Centers (GFCs) are dedicated treatment units where care is tailored towards elderly patients who have suffered fragility fractures. The primary objective of this economic analysis was to determine the cost-utility of GFCs compared with usual care centres. METHODS: The primary analysis was a cost-utility analysis that measured the cost per incremental quality-adjusted life-year gained from treatment of hip fracture in GFCs compared with treatment in usual care centres from the societal perspective over a 1-year time horizon. The secondary analysis was a cost-utility analysis from a societal perspective over a lifetime time horizon. We evaluated these outcomes using a cost-utility analysis using data from a large multicentre prospective cohort study comparing GFCs versus usual care centres that took place in Austria, Spain, the USA, the Netherlands, Thailand and Singapore. RESULTS: GFCs may be cost-effective in the long term, while providing a more comprehensive care plan. Patients in usual care centre group were slightly older and had fewer comorbidities. For the 1-year analysis, the costs per patient were slightly lower in the GFC group (-$646.42), while the quality-adjusted life-years were higher in the usual care centre group (+0.034). The incremental cost-effectiveness ratio was $18 863.34 (US$/quality-adjusted life-year). The lifetime horizon analysis found that the costs per patient were lower in the GFC group (-$7210.35), while the quality-adjusted life-years were higher in the usual care centre group (+0.02). The incremental cost-effectiveness ratio was $320 678.77 (US$/quality-adjusted life-year). CONCLUSIONS: This analysis found that GFCs were associated with lower costs compared with usual care centres. The cost-savings were greater when the lifetime time horizon was considered. This comprehensive cost-effectiveness analysis, using data from an international prospective cohort study, found that GFC may be cost-effective in the long term, while providing a more comprehensive care plan. A greater number of major adverse events were reported at GFC, nevertheless a lower mortality rate associated with these adverse events at GFC. Due to the minor utility benefits, which may be a result of greater adverse event detection within the GFC group and much greater costs of usual care centres, the GFC may be cost-effective due to the large cost-savings it demonstrated over the lifetime time horizon, while potentially identifying and treating adverse events more effectively. These findings suggest that the GFC may be a cost-effective option over the lifetime of a geriatric patient with hip fracture, although future research is needed to further validate these findings. LEVEL OF EVIDENCE: Economic, level 2. TRIAL REGISTRATION NUMBER: NCT02297581.

Targeted optimum care approach for osteoporotic fragility fractures: tailored strategy based on risk stratification to reduce incidents of falls-an initiative by the Egyptian Academy of bone health based on the FLS national register.

Since falling is the third cause of chronic disability, a better understanding of the frequency, severity, and risk factors of falls across diagnostic groups is needed to design and implement customized, effective fall prevention, and management programs for these individuals, particularly those at risk of sustaining a fragility fracture. OBJECTIVE: (1) To assess the incidence of falls among osteoporotic patients with fragility fractures. (2) To evaluate the potential for stratifying the people at risk of falling in bone health setting aiming to provide targeted optimum care for them. METHODS: This was a multi-center, cross-sectional, observational study. Both men and postmenopausal women, admitted with an osteoporotic fracture (whether major osteoporosis or hip fracture), were consecutively recruited for this work and managed under Fracture Liaison Service. All the patients were assessed for their Fracture risk (FRAX), falls risk (FRAS), and sarcopenia risk (SARC-F) as well as functional disability (HAQ). Blood tests for bone profile as well as DXA scan were offered to all the patients. RESULTS: Four hundred five patients (121 males, 284 females) were included in this work. Mean age was 70.1 (SD = 9.2) years. The incidence of falls was 64.9%. The prevalence of falls was high (64.8%) in the patients presenting with major osteoporosis fractures and in those with hip fractures (61.8%). The prevalence of fragility fractures was positively correlated with HAQ score and the SARC-F score (p = 0.01 and 0.021 respectively). Falls risk score was positively correlated with FRAX score of major osteoporotic fractures, HAQ score, and SARC-F score (p = 0.01, 0.013, and 0.003 respectively). Seventy percent of the osteopenia patients who sustained fragility fracture had high falls risk and/or SARC-F score. CONCLUSION: This study highlighted the importance of falls risk stratification in osteoporotic patients presenting with fragility fractures. Identification of the patients at increased risk of falls should be a component of the standard practice.

Outcomes of hip fracture in centenarians: a systematic review and meta-analysis.

PURPOSE: Outcomes of hip fractures in centenarians remain underreported owing to the small number of patients reaching 100 years of age. This review aimed to determine outcomes of hip fracture in centenarians and to identify the most common comorbidities among centenarians with hip fracture to better characterise this population. METHODS: Published and unpublished literature databases, conference proceedings and the reference lists of included studies were searched to the 25th of January 2023. A random-effects meta-analysis was performed. Included studies were appraised using tools respective of study design. RESULTS: Twenty-three studies (6970 centenarians) were included (retrospective period: 1990-2020). The evidence was largely moderate to low in quality. One-year mortality following a hip fracture was 53.8% (95% CI 47.2 to 60.3%). Pooled complication rate following a hip fracture in centenarians was 50.5% (95% CI 25.3 to 75.6%). Dementia (26.2%, 95% CI 15.7 to 38.2%), hypertension (15.6%, 95% CI 3.4 to 33.1%), and diabetes (5.5%, 95% CI 1.9 to 10.7%) were the most common comorbidities among centenarians with hip fracture. CONCLUSION: Hip fractures in centenarians typically involve complex patient presentations with diverse comorbidities. However, the current evidence-base is moderate to low in quality. Effective cross-discipline communication and intervention is suggested to promote treatment outcomes.

Comparative effectiveness of different exercise interventions for elderly patients with hip fracture: A systematic review and Bayesian network meta-analysis protocol of randomized controlled trials.

BACKGROUND: Exercise intervention (EI) is a promising and economical way for elderly patients with hip fracture, but the evidence regarding effective EIs remains fragmented and controversial, and it is unclear which type of exercise is optimal. The purpose of this Bayesian network meta-analysis (NMA) is to compare and rank the efficacy of various EIs in elderly patients with hip fracture. MATERIALS AND METHODS: A comprehensive literature search was performed using a systematic approach across various databases including Medline (via PubMed), CINAHL, CNKI, Web of Science, Wan Fang, Embase, VIP, Cochrane Central Register of Controlled Trials and CBM databases. The search encompasses all available records from the inception of each database until December 2022. The Inclusion literature comprises randomized controlled trials that incorporate at least one EI for elderly patients with hip fracture. We will assess the risk of bias of the studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions, and assess each evidence of outcome quality in accordance with the Grading of Recommendations Assessment, Development and Evaluation framework. The NMA will be performed by STATA 15.0 software and OpenBUGS version 3.2.3. The identification of publication bias will be accomplished through the utilization of a funnel plot. We will rank the EIs effects according to the cumulative ranking probability curve (surface under the cumulative ranking area, SUCRA). The primary outcomes will be hip function in elderly patients, and the secondary outcomes will be activities of daily living, walking capacity and balance ability of elderly patients. TRIAL REGISTRATION: PROSPERO registration number: CRD4202022340737.

Physiotherapists' perspectives of barriers and facilitators to effective community provision after hip fracture: a qualitative study in England.

PURPOSE: to investigate physiotherapists' perspectives of effective community provision following hip fracture. METHODS: qualitative semi-structured interviews were conducted with 17 community physiotherapists across England. Thematic analysis drawing on the Theoretical Domains Framework identified barriers and facilitators to implementation of effective provision. Interviews were complemented by process mapping community provision in one London borough, to identify points of care where suggested interventions are in place and/or could be implemented. RESULTS: four themes were identified: ineffective coordination of care systems, ineffective patient stratification, insufficient staff recruitment and retention approaches and inhibitory fear avoidance behaviours. To enhance care coordination, participants suggested improving access to social services and occupational therapists, maximising multidisciplinary communication through online notation, extended physiotherapy roles, orthopaedic-specific roles and seven-day working. Participants advised the importance of stratifying patients on receipt of referrals, at assessment and into appropriately matched interventions. To mitigate insufficient staff recruitment and retention, participants proposed return-to-practice streams, apprenticeship schemes, university engagement, combined acute-community rotations and improving job description advertisements. To reduce effects of fear avoidance behaviour on rehabilitation, participants proposed the use of patient-specific goals, patient and carer education, staff education in psychological strategies or community psychologist access. Process mapping of one London borough identified points of care where suggested interventions to overcome barriers were in place and/or could be implemented. CONCLUSION: physiotherapists propose that effective provision of community physiotherapy following hip fracture could be improved by refining care coordination, utilising stratification techniques, employing enhanced recruitment and retainment strategies and addressing fear avoidance behaviours.

Epidemiology and treatment of proximal femoral fractures in the elderly U.S. population.

Proximal femoral fractures are a serious complication, especially for elderly patients. Detailed epidemiological analyzes provide a valuable resource for stakeholders in the health care system in order to foresee future development possibly influenceable by adaption of therapeutic procedures and prevention strategies. This work aimed at answering the following research questions: (1) What are the incidence rates of proximal femoral fractures in the elderly U.S. population? (2) What is the preferred treatment procedure for these fractures? Proximal femoral fractures occurred between January 1, 2009 and December 31, 2019 in patients ≥ 65 years were identified from the Medicare Physician Service Records Data Base. The 5% sample of Medicare beneficiaries, equivalent to the records from approximately 2.5 million enrollees formed the basis of this study. Fractures were grouped into head/neck, intertrochanteric, and subtrochanteric fractures. The overall incidence rate, age and sex specific incidence rates as well as incidence rate ratios were calculated. Common Procedural Terminology (CPT) codes were used to identify procedures and operations. In 2019, a total number of 7982 femoral head/neck fractures was recorded. In comparison to 9588 cases in 2009, the incidence substantially decreased by 26.6% from 666.7/100,000 inhabitants to 489.3/100,000 inhabitants (z = - 5.197, p < 0.001). Also, in intertrochanteric fractures, a significant decline in the incidence by 17.3% was evident over the years from 367.7/100,000 inhabitants in 2009 to 304.0 cases per 100,000 inhabitants in 2019 (z = - 2.454, p = 0.014). A similar picture was observable for subtrochanteric fractures, which decreased by 29.6% (51.0 cases per 100,000 to 35.9 cases per 100,000) over the time period (z = - 1.612, p = 0.107). Head/neck fractures were mainly treated with an arthroplasty (n = 36,301, 40.0%). The majority of intertrochanteric fractures and subtrochanteric fractures received treatment with an intramedullary device (n = 34,630, 65.5% and n = 5870, 77.1%, respectively). The analysis indicated that the incidence of all types of proximal femoral neck fractures decreased for the population of elderly patients in the U.S. within the last decade. Treatment of head and neck fractures was mainly conducted through arthroplasty, while intertrochanteric and subtrochanteric fractures predominantly received an intramedullary nailing.

Development of a conceptual framework to scale up co-managed care for older patients with hip fracture in China: a qualitative study.

BACKGROUND: Hip fracture creates a major burden on society due to high mortality, loss of independence and excess medical costs for older people. A multidisciplinary co-managed model of care is widely considered as the best practice for the management of older patients with hip fracture. The study aims to develop a conceptual framework to inform the future scale-up of this model of care through the identification of barriers and enablers that may influence successful uptake. METHODS: This qualitative study was conducted within an interventional study, which aimed to test the effectiveness of co-managed model of care for older patients with hip fracture. Health providers and health administrators from three hospitals were purposively selected and interviewed in-depth. The Consolidated Framework for Implementation Research (CFIR) was used to develop interview guides, collect and analyse data. Inductive and deductive approaches were used to generate enablers or barriers, aligned with the CFIR constructs. All barriers or enablers were inductively summarised to a conceptual framework with essential components to guide the implementation of co-managed model of care in other hospitals. RESULTS: A total of 13 health providers and 3 health administrators were recruited. The main barriers to co-managed care implementation included perceived complexity of implementation, insufficient international collaboration and incentives, the absence of national guideline support and lack of digital health applications for communication between health providers, insufficient number of health providers and beds, and poor understanding about the effectiveness of this care model. A conceptual framework for future scale-up was then developed, consisting of the following essential components: hospital authority support, enabling environment, adequate number of beds, sufficient and skilled health providers, use of digital health technology, regular quality supervision, evaluation and feedback, and external collaborations. CONCLUSIONS: Despite the complexity of the intervention, the co-managed model of care has the potential to be implemented and promoted in China and in similar settings, although there is a need to demonstrate feasibility in different settings.

Unpaid caregiving for people following hip fracture: longitudinal analysis from the English Longitudinal Study of Ageing.

PURPOSE: To determine the provision and its change over time in unpaid care for people following hip fracture. METHODS: Data were sought from the English Longitudinal Study of Ageing (ELSA) cohort. We identified participants who self-reported experiencing a hip fracture, who had clinical and caregiving data in the previous and subsequent two data collection waves. Demographic and clinical data were collected in addition to data on provision of unpaid care, who provided care and the frequency of needs being met. RESULTS: The analysed cohort consisted of 246 participants [150 females (61%), mean age 78.9 years (standard deviation: 8.6)]. There was an increase in the number of participants requiring unpaid care between the Pre-Fracture and Fracture Wave (29% vs. 59%), which plateaued in the subsequent two waves (56%; 51%). Although both spouse and daughters provided the most unpaid care to participants over this study period, there was an increase in support provided during the Fracture Wave by both sons and daughters. This increased support offered by spouses continued until Post-Fracture Wave 2 when this plateaued. Support provided by friends increased from 3 to 8% and brothers and sisters increased from 0 and 1% Pre-Fracture to 8% by Post-Fracture Wave 2. CONCLUSION: These findings provide insights into who, what and how unpaid carers support people following hip fracture over time. Given the level of support unpaid carers offer, and previously reported carer stress and burden, undertaking clinical trials to assess the effectiveness of carer-patient support interventions would be valuable.

Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study.

BACKGROUND: Hip fracture care delivery varies between hospitals, which might explain variations in patient outcomes and health costs. The aim of this study was to identify hospital-level organisational factors associated with long-term patient outcomes and costs after hip fracture. METHODS: REDUCE was a record-linkage cohort study in which national databases for all patients aged 60 years and older who sustained a hip fracture in England and Wales were linked with hospital metrics from 18 organisational data sources. Multilevel models identified organisational factors associated with the case-mix adjusted primary outcomes: cumulative all-cause mortality, days spent in hospital, and inpatient costs over 365 days after hip fracture. FINDINGS: Between April 1, 2016, and March 31, 2019, 178 757 patients with an index hip fracture were identified from 172 hospitals in England and Wales. 126 278 (70·6%) were female, 52 479 (29·4%) were male, and median age was 84 years (IQR 77-89) in England and 83 years (77-89) in Wales. 365 days after hip fracture, 50 354 (28·2%) patients had died. Patients spent a median 21 days (IQR 11-41) in hospital, incurring costs of £14 642 (95% CI 14 600-14 683) per patient, ranging from £10 867 (SD 5880) to £23 188 (17 223) between hospitals. 11 organisational factors were independently associated with mortality, 24 with number of days in hospital, and 25 with inpatient costs. Having all patients assessed by an orthogeriatrician within 72 h of admission was associated with a mean cost saving of £529 (95% CI 148-910) per patient and a lower 365-day mortality (odds ratio 0·85 [95% CI 0·76-0·94]). Consultant orthogeriatrician attendance at clinical governance meetings was associated with cost savings of £356 (95% CI 188-525) and 1·47 fewer days (95% CI 0·89-2·05) in the hospital in the 365 days after hip fracture per patient. The provision of physiotherapy to patients on weekends was associated with a cost saving of £676 (95% CI 67-1285) per patient and with 2·32 fewer days (0·35-4·29) in hospital in the 365 days after hip fracture. INTERPRETATION: Multiple, potentially modifiable hospital-level organisational factors associated with important clinical outcomes and inpatient costs were identified that should inform initiatives to improve the effectiveness and efficiency of hip fracture services. FUNDING: Versus Arthritis.

Patients' recovery of mobility and return to original residence after hip fracture are associated with multiple modifiable components of hospital service organisation: the REDUCE record-linkage cohort study in England and Wales.

BACKGROUND: Hip fractures are devastating injuries causing disability, dependence, and institutionalisation, yet hospital care is highly variable. This study aimed to determine hospital organisational factors associated with recovery of mobility and change in patient residence after hip fracture. METHODS: A cohort of patients aged 60 + years in England and Wales, who sustained a hip fracture from 2016 to 2019 was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality records were linked to 101 factors derived from 18 hospital-level organisational metrics. After adjustment for patient case-mix, multilevel models were used to identify organisational factors associated with patient residence at discharge, and mobility and residence at 120 days after hip fracture. RESULTS: Across 172 hospitals, 165,350 patients survived to discharge, of whom 163,230 (99%) had post-hospital discharge destination recorded. 18,323 (11%) died within 120 days. Among 147,027 survivors, 58,344 (40%) across 143 hospitals had their residence recorded, and 56,959 (39%) across 140 hospitals had their mobility recorded, at 120 days. Nineteen organisational factors independently predicted residence on hospital discharge e.g., return to original residence was 31% (95% confidence interval, CI:17-43%) more likely if the anaesthetic lead for hip fracture had time allocated in their job plan, and 8-13% more likely if hip fracture service clinical governance meetings were attended by an orthopaedic surgeon, physiotherapist or anaesthetist. Seven organisational factors independently predicted residence at 120 days. Patients returning to their pre-fracture residence was 26% (95%CI:4-42%) more likely if hospitals had a dedicated hip fracture ward, and 20% (95%CI:8-30%) more likely if treatment plans were proactively discussed with patients and families on admission. Seventeen organisational factors predicted mobility at 120 days. More patients re-attained their pre-fracture mobility in hospitals where (i) care involved an orthogeriatrician (15% [95%CI:1-28%] improvement), (ii) general anaesthesia was usually accompanied by a nerve block (7% [95%CI:1-12%], and (iii) bedside haemoglobin testing was routine in theatre recovery (13% [95%CI:6-20%]). CONCLUSIONS: Multiple, potentially modifiable, organisational factors are associated with patient outcomes up to 120 days after a hip fracture, these factors if causal should be targeted by service improvement initiatives to reduce variability, improve hospital hip fracture care, and maximise patient independence.