Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study
TL;DR: In elderly people with hip fracture, the presence of three or more comorbidities is the strongest preoperative risk factor and lead to increased mortality.
Abstract: Objectives To evaluate postoperative medical complications and the association between these complications and mortality at 30 days and one year after surgery for hip fracture and to examine the association between preoperative comorbidity and the risk of postoperative complications and mortality. Design Prospective observational cohort study. Setting University teaching hospital. Participants 2448 consecutive patients admitted with an acute hip fracture over a four year period. We excluded 358 patients: all those aged Interventions Routine care for hip fractures. Main outcome measures Postoperative complications and mortality at 30 days and one year. Results Mortality was 9.6% at 30 days and 33% at one year. The most common postoperative complications were chest infection (9%) and heart failure (5%). In patients who developed postoperative heart failure mortality was 65% at 30 days (hazard ratio 16.1, 95% confidence interval 12.2 to 21.3). Of these patients, 92% were dead by one year (11.3, 9.1 to 14.0). In patients who developed a postoperative chest infection mortality at 30 days was 43% (8.5, 6.6 to 11.1). Significant preoperative variables for increased mortality at 30 days included the presence of three or more comorbidities (2.5, 1.6 to 3.9), respiratory disease (1.8, 1.3 to 2.5), and malignancy (1.5, 1.01 to 2.3). Conclusions In elderly people with hip fracture, the presence of three or more comorbidities is the strongest preoperative risk factor. Chest infection and heart failure are the most common postoperative complications and lead to increased mortality. These groups offer a clear target for specialist medical assessment.
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TL;DR: Older adults have a 5- to 8-fold increased risk for all-cause mortality during the first 3 months after hip fracture, and excess annual mortality after hip fractures is higher in men than in women.
Abstract: Interest is increasing in quantifying the magnitude and duration of excess mortality after hip fractures for use in cost-effectiveness analyses of strategies for hip fracture prevention (1-3). Although an increased risk for death after hip fracture is well established in both women and men, it is unclear whether this excess mortality persists over time (4).
Although almost all studies have reported an increased risk for death in the first 3 to 6 months after injury, results from long-term (5- to 10-year) follow-up have been conflicting, with some studies finding persistent excess mortality and others finding none (5-8). These conflicting results have several potential causes, including differences in control populations, difficulties in comparing crude and adjusted mortality statistics, and differences in model covariates (4-6, 9-16). At longer follow-up, the number of patients at risk and therefore the number of events (deaths) provide limited statistical power (17). An additional source of variability occurs in time-to-event (survival) analyses when the mortality risk is not constant over time and follow-up varies across the cohorts (17, 18). Because of these factors, reported hazard estimates are varied and have wide CIs, limiting any inferences physicians or public health policymakers can make. Further drawbacks include limited sample size, low frequency of observations, lack of stratification by sex, and reporting relative rather than absolute risks (17, 19, 20).
We summarize longitudinal evidence about the magnitude and duration of excess mortality after hip fracture in older men and women.
1,084 citations
Cites background from "Effect of comorbidities and postope..."
...These include postoperative events associated with hip surgery, such as pulmonary embolism (68), infectious complications (69, 70), heart failure (69, 70), or cardiovascular or pulmonary complications (64)....
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TL;DR: Observations show that patients are at increased risk for premature death for many years after a fragility-related hip fracture and highlight the need to identify those patients who are candidates for interventions to reduce their risk.
Abstract: This systematic literature review has shown that patients experiencing hip fracture after low-impact trauma are at considerable excess risk for death compared with nonhip fracture/community control populations. The increased mortality risk may persist for several years thereafter, highlighting the need for interventions to reduce this risk.Patients experiencing hip fracture after low-impact trauma are at considerable risk for subsequent osteoporotic fractures and premature death. We conducted a systematic review of the literature to identify all studies that reported unadjusted and excess mortality rates for hip fracture. Although a lack of consistent study design precluded any formal meta-analysis or pooled analysis of the data, we have shown that hip fracture is associated with excess mortality (over and above mortality rates in nonhip fracture/community control populations) during the first year after fracture ranging from 8.4% to 36%. In the identified studies, individuals experienced an increased relative risk for mortality following hip fracture that was at least double that for the age-matched control population, became less pronounced with advancing age, was higher among men than women regardless of age, was highest in the days and weeks following the index fracture, and remained elevated for months and perhaps even years following the index fracture. These observations show that patients are at increased risk for premature death for many years after a fragility-related hip fracture and highlight the need to identify those patients who are candidates for interventions to reduce their risk.
878 citations
TL;DR: There is no conclusive evidence of the preoperative predictors for mortality following hip fractures, and special attention should be paid to the above 12 strong evidence predictors.
Abstract: Background Hip fractures are always associated with a high postoperative mortality, the preoperative predictors for mortality have neither been well identified or summarised. This systematic review and meta-analysis was performed to identify the preoperative non-interventional predictors for mortality in hip fracture patients, especially focused on 1 year mortality. Methods Non-interventional studies were searched in Pubmed, Embase, Cochrane central database (all to February 26th, 2011). Only prospective studies and retrospective studies with prospective collected data were included. Qualities of included studies were assessed by a standardised scale previous reported for observational studies. The effects of individual studies were combined with the study quality score using a previous reported model of best-evidence synthesis. The hazard ratios of strong evidence predictors were combined only by high quality studies. Results 75 included studies with 94 publications involving 64,316 patients were included and the available observations was a heterogeneous group. The overall inpatient or 1 month mortality was 13.3%, 3–6 months was 15.8%, 1 year 24.5% and 2 years 34.5%. There were strong evidence for 12 predictors, including advanced age, male gender, nursing home or facility residence, poor preoperative walking capacity, poor activities of daily living, higher ASA grading, poor mental state, multiple comorbidities, dementia or cognitive impairment, diabetes, cancer and cardiac disease. We also identified 7 moderate evidence and 12 limited evidence mortality predictors, and only the race was identified as the conflicting evidence predictor. Conclusion Whilst there is no conclusive evidence of the preoperative predictors for mortality following hip fractures, special attention should be paid to the above 12 strong evidence predictors. Future researches were still needed to evaluate the effects of these predictors.
498 citations
TL;DR: Men were more likely than women to die from respiratory disease, malignant neoplasm, and circulatory disease after hip fracture, while the most common causes of death were circulatory diseases, followed by dementia and Alzheimer's disease.
Abstract: The high mortality of hip fracture patients is well documented, but sex- and cause-specific mortality after hip fracture has not been extensively studied. The purpose of the present study was to evaluate mortality and cause of death in patients after hip fracture surgery and to compare their mortality and cause of death to those in the general population. Records of 428 consecutive hip fracture patients were collected on a population-basis and data on the general population comprising all Finns 65 years of age or older were collected on a cohort-basis. Cause of death was classified as follows: malignant neoplasms, dementia, circulatory disease, respiratory disease, digestive system disease, and other. Mean follow-up was 3.7 years (range 0-9 years). Overall 1-year postoperative mortality was 27.3% and mortality after hip fracture at the end of the follow-up was 79.0%. During the follow-up, age-adjusted mortality after hip fracture surgery was higher in men than in women with hazard ratio (HR) 1.55 and 95% confidence interval (95% CI) 1.21-2.00. Among hip surgery patients, the most common causes of death were circulatory diseases, followed by dementia and Alzheimer's disease. After hip fracture, men were more likely than women to die from respiratory disease, malignant neoplasm, and circulatory disease. During the follow-up, all-cause age- and sex-standardized mortality after hip fracture was 3-fold higher than that of the general population and included every cause-of-death category. During the study period, the risk of mortality in hip fracture patients was 3-fold higher than that in the general population and included every major cause of death.
437 citations
Cites background from "Effect of comorbidities and postope..."
...Hip fracture is the most serious consequence of falling in older people with osteoporosis; 87% to 96% of hip fracture patients are 65 years of age or older [1,2]....
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...Excess mortality after hip fracture may be linked to complications following the fracture, such as pulmonary embolism [5], infections [2,6], and heart failure [2,6]....
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...Specialist medical assessment and management of older people with hip fracture before and after surgery have been recommended [2]....
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TL;DR: Higher age and multimorbidity is found to be related to an increased risk of dying within the first year after fracture; acute complications might be one of the explanations.
Abstract: Introduction: osteoporosis is a common disease, and the incidence of osteoporotic fractures is expected to rise with the growing elderly population. Immediately following, and probably several years after a hip fracture, patients, both men and women, have a higher risk of dying compared to the general population regardless of age. The aim of this study was to assess excess mortality following hip fracture and, if possible, identify reasons for the difference between mortality for the two genders. Methods: this is a nationwide register-based cohort study presenting data from the National Hospital Discharge Register on mortality, comorbidity and medication for all Danish patients (more than 41,000 persons) experiencing a hip fracture between 1 January 1999 and 31 December 2002. Follow-up period was until 31 December 2005. Results: we found a substantially higher mortality among male hip fracture patients than female hip fracture patients despite men being 4 years younger at the time of fracture. Both male and female hip fracture patients were found to have an excess mortality rate compared to the general population. The cumulative mortality at 12 months among hip fracture patients compared to the general population was 37.1% (9.9%) in men and 26.4% (9.3%) in women. In the first year, the risk of death significantly increased for women with increasing age (hazard ratio, HR: 1.06, 95% confidence interval, CI: 1.06–1.07), the number of comedications (HR 1.04, 95% CI 1.03–1.05) and the presence of specific Charlson index components and medications described below. For men, age (HR 1.07, 95% CI 1.07–1.08), number of comedications (HR 1.06, 95% CI 1.04– 1.07) and presence of different specific Charlson index components and medications increased the risk. Long-term survival analyses revealed that excess mortality for men compared with women remained strongly significant (HR 1.70, 95% CI 1.65– 1.75, P < 0.001), even when controlled for age, fracture site, the number of medications, exposure to drug classes A, C, D, G, J, M, N, P, S and for chronic comorbidities. Conclusion: excess mortality among male patients cannot be explained by controlling for known comorbidity and medications. Besides gender, we found higher age and multimorbidity to be related to an increased risk of dying within the first year after fracture; acute complications might be one of the explanations. This study emphasises the need for particular rigorous postoperative diagnostic evaluation and treatment of comorbid conditions in the male hip fracture patient.
430 citations
Cites background from "Effect of comorbidities and postope..."
...Male gender has been shown to be predictive of high risk of postoperative complications such as chest infections and heart failure [8]....
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References
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TL;DR: Perioperative increase of oxygen delivery with dopexamine hydrochloride significantly reduces mortality and morbidity in high-risk surgical patients.
Abstract: Objective —To assess the effect of deliberate perioperative increase in oxygen delivery on mortality and morbidity in patients who are at high risk of both following surgery Design —Prospective, randomized clinical trial Setting —A teaching hospital general intensive care unit, London, England Patients —A total of 107 surgical patients, who were assessed as high risk from previously identified criteria, were studied during an 18-month period Interventions —Patients were randomly assigned to a control group (n=54) that received best standard perioperative care, or to a protocol group (n=53) that, in addition, had deliberate increase of oxygen delivery index to greater than 600 mL/min per square meter by use of dopexamine hydrochloride infusion Outcome Measures —Mortality and complications were assessed to 28 days postoperatively Results —Groups were similar with respect to demographics, admission criteria, operation type, and admission hemodynamic variables Groups were treated similarly to maintain blood pressure, arterial saturation, hemoglobin concentration, and pulmonary artery occlusion pressure; however, once additional treatment with dopexamine hydrochloride had been given, the protocol group had significantly higher oxygen delivery preoperatively (median, 597 vs 399 mL/min per square meter;P Conclusion —Perioperative increase of oxygen delivery with dopexamine hydrochloride significantly reduces mortality and morbidity in high-risk surgical patients (JAMA 1993;270:2699-2707)
934 citations
TL;DR: The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality and morbidity, greater in patients with an extracapsular fracture.
Abstract: OBJECTIVE--To study the mortality and morbidity associated with proximal femoral fractures with reference to fracture type (intracapsular and extracapsular). DESIGN--Consecutive prospective study with 12 month follow ups. SETTING--Two British trauma receiving centres. PATIENTS--1000 consecutive acute proximal femoral fractures (fractured necks of femur) in 972 patients. RESULTS--Significantly higher mortality at one year was seen in patients with extracapsular fractures (188/490; 38%) than in those with intracapsular fractures (147/510; 29%; p < 0.01). Greater morbidity was experienced during the study period by patients with extracapsular fractures, who were less mobile and less independent at the time of their injury. CONCLUSIONS--The rise in average age of presentation with proximal femoral fracture is associated with a persistently high mortality (33%) and morbidity, greater in patients with an extracapsular fracture. Comparison with other studies, principally from outside Britain, is difficult, but despite advancing standards of care the mortality and morbidity of femoral neck fractures remains high, placing an ever increasing burden on the health service.
882 citations
TL;DR: Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery, however, a delay of more than four days significantly increased mortality.
Abstract: Background: Hip fracture is associated with high mortality among the elderly. Most patients require surgery, but the timing of the operation remains controversial. Surgery within twenty-four hours after admission has been recommended, but evidence supporting this approach is lacking. The objective of this study was to determine whether a delay in surgery for hip fractures affects postoperative mortality among elderly patients.
Methods: We conducted a prospective, observational study of 2660 patients who underwent surgical treatment of a hip fracture at one university hospital. We measured mortality rates following the surgery in relation to the delay in the surgery and the acute medical comorbidities on admission.
Results: The mortality following the hip fracture surgery was 9% (246 of 2660) at thirty days, 19% at ninety days, and 30% at twelve months. Of the patients who had been declared fit for surgery, those operated on without delay had a thirty-day mortality of 8.7% and those for whom the surgery had been delayed between one and four days had a thirty-day mortality of 7.3%. This difference was not significant (p = 0.51). The thirty-day mortality for patients for whom the surgery had been delayed for more than four days was 10.7%, and this small group had significantly increased mortality at ninety days (hazard ratio = 2.25; p = 0.001) and one year (hazard ratio = 2.4; p = 0.001). Patients who had been admitted with an acute medical comorbidity that required treatment prior to the surgery had a thirty-day mortality of 17%, which was nearly 2.5 times greater than that for patients who had been initially considered fit for surgery (hazard ratio = 2.3, 95% confidence interval = 1.6 to 3.3; p < 0.001).
Conclusions: The thirty-day mortality following surgery for a hip fracture was 9%. Patients with medical comorbidities that delayed surgery had 2.5 times the risk of death within thirty days after the surgery compared with patients without comorbidities that delayed surgery. Mortality was not increased when the surgery was delayed up to four days for patients who were otherwise fit for hip fracture surgery. However, a delay of more than four days significantly increased mortality.
Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
685 citations
TL;DR: The recommendation is for serious medical conditions to be maximally stabilized for at least 24 hours and pulmonary and physical therapy instituted before scheduling open surgical procedures.
Abstract: This retrospective analysis of 406 patients with proximal femoral fractures was designed to identify both the significant and nonsignificant risk factors that influence patient mortality. The 399 patients treated by open reduction and internal fixation or femoral head prostheses routinely received prophylactic antibiotics and anticoagulants. Of 406 patients followed until death or for at least one year, the overall mortality rate at one year was 14% (58/406). For patients with subcapital fractures the rate was 13% (25/187) and with intertrochanteric fractures 15% (33/219). The expected mortality rate for the normal population of similar age was about 9%. Sex, treatment of subcapital fracture by either internal fixation or arthroplasty, and the level of postoperative ambulation did not influence mortality. The number of preexisting medical conditions and the time of surgery following admission were highly significant factors (p less than or equal to 0.001 for both). The number of postoperative medical complications was also significant. The recommendation is for serious medical conditions to be maximally stabilized for at least 24 hours and pulmonary and physical therapy instituted before scheduling open surgical procedures.
496 citations