Fast track hip fracture care and mortality – an observational study of 2230 patients

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Abstract

Background

Hip fracture patients are frail and have a high mortality. We investigated whether the introduction of fast track care reduced the 30-day mortality after hip fractures.

Methods

Fast track hip fracture care was established at our institution in October 2013. Data from the Norwegian Hip Fracture Register and electronic hospital records were merged for 2230 hip fracture patients operated in our department from January 2012 through December 2015. 1090 of these patients were operated before (conventional treatment group) and 1140 patients were operated after the introduction of fast track care (fast track group). Data were analysed by univariate analysis and binary logistic regression.

Results

Mortality did not differ significantly between the conventional treatment group and the fast track group at 30 days (7.9% vs. 6.5%), 90 days (13.5% vs. 12.5%) and one year (22.8% vs. 22.8%). Median admission time and time to surgery were significantly shorter in the fast track group than in the conventional treatment group (1.1 h vs. 3.9 h and 23.6 h vs. 25.7 h, both p < 0.0001). The 30-day reoperation rate was significantly lower in the fast track group compared to the conventional treatment group (odds ratio = 0.35 (95% CI: 0.15–0.84), p = 0.019). A composite 30-day outcome (reoperation, surgical site infection and/or death) was significantly less frequent in the fast track group (8.1%) than in the conventional treatment group (10.7%) in unadjusted analysis ( p = 0.006), but not after adjusting for age, gender, cognitive impairment and ASA score (odds ratio = 0.85 (95% CI: 0.63–1.16), p = 0.31, 8.0% missing). Reoperations within 1 year, surgical site infections, 30-day readmissions and length of hospital stay did not differ significantly between the conventional treatment group and the fast track group.

Conclusions

Fast track hip fracture care is safe. However, we observed no statistically significant change in 30-day, 90-day or 1-year mortality after the introduction of fast track hip fracture care.

Trial registration

The study was registered retrospectively at ClinicalTrials.gov (Protocol Record 284907) 6 December 2016.

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Most cited references 24

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Early mortality after hip fracture: is delay before surgery important?

Ronald K. Taylor, Allisyn Moran, Russell T Wenn … (2005)

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. 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. 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). 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.

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Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients.

Gitte Holm, Steffen Jacobsen, Henrik Husted (2008)

Very few studies have focused on patient characteristics that influence length of stay (LOS) in fast-track total hip (THR) and knee arthroplasty (TKR). The aim of this prospective study was to identify patient characteristics associated with LOS and patient satisfaction after total hip and knee replacement surgery. Between September 2003 and December 2005, 712 consecutive, unselected patients (440 women) with a mean age of 69 (31-91) years were admitted for hip and knee replacement surgery at our specialized fast-track joint replacement unit. Epidemiological, physical, and perioperative parameters were registered and correlated to LOS and patient satisfaction. 92% of the patients were discharged directly to their homes within 5 days, and 41% were discharged within 3 days. Age, sex, marital status, co-morbidity, preoperative use of walking aids, pre- and postoperative hemoglobin levels, the need for blood transfusion, ASA score, and time between surgery and mobilization, were all found to influence postoperative outcome in general, and LOS and patient satisfaction in particular. We identified several patient characteristics that influence postoperative outcome, LOS, and patient satisfaction in our series of consecutive fast-track joint replacement patients, enabling further attention to be paid to certain aspects of surgery and rehabilitation.

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Similar mortality rates in hip fracture patients over the past 31 years

Simran Mundi, Bharadwaj Pindiprolu, Nicole Simunovic … (2014)

Background Over 320,000 hip fractures occur in North America each year and they are associated with a mortality rate ranging from 14% to 36% within 1 year of surgery. We assessed whether mortality and reoperation rates have improved in hip fracture patients over the past 31 years. Methods 3 electronic databases were searched for randomized controlled trials on hip fracture management, published between 1950 and 2013. Articles that assessed the surgical treatment of intertrochanteric or femoral neck fractures and measured mortality and/or reoperation rates were obtained. We analyzed overall mortality and reoperation rates, as well as mortality rates by fracture type, comparing mean values in different decades. Our primary outcome was the change in 1-year postoperative mortality. Results 70 trials published between 1981 and 2012 were included in the review. Overall, the mean 1-year mortality rate changed from 24% in the 1980s to 23% in the 1990s, and to 21% after 1999 (p = 0.7). 1-year mean mortality rates for intertrochanteric fractures diminished from 34% to 23% in studies published before 2000 and after 1999 (p = 0.005). Mean mortality rates for femoral neck fractures were similar over time (∼20%). Reoperation rates were also similar over time. Interpretation We found similar mortality and reoperation rates in surgically treated hip fracture patients over time, with the exception of decreasing mortality rates in patients with intertrochanteric fractures.

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Author and article information

Contributors

Christian Thomas Pollmann:

ORCID: http://orcid.org/0000-0002-3869-0129

Christian.Pollmann@ahus.no

Jan Harald Røtterud: Jan.H.Myhreng.Rotterud@ahus.no

Jan-Erik Gjertsen: jan-erik.gjertsen@helse-bergen.no

Fredrik Andreas Dahl: Fredrik.A.Dahl@ahus.no

Olav Lenvik: Olav.Lenvik@ahus.no

Asbjørn Årøen: asbjorn.aroen@medisin.uio.no

Journal

Journal ID (nlm-ta): BMC Musculoskelet Disord

Journal ID (iso-abbrev): BMC Musculoskelet Disord

Title: BMC Musculoskeletal Disorders

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2474

Publication date (Electronic): 24 May 2019

Publication date PMC-release: 24 May 2019

Publication date Collection: 2019

Volume: 20

Electronic Location Identifier: 248

Affiliations

[1 ]ISNI 0000 0000 9637 455X, GRID grid.411279.8, Department of Orthopaedic Surgery, , Akershus University Hospital, ; Lørenskog, Norway

[2 ]ISNI 0000 0004 1936 8921, GRID grid.5510.1, Institute of Clinical Medicine, Campus Ahus, , University of Oslo, ; Oslo, Norway

[3 ]ISNI 0000 0000 9753 1393, GRID grid.412008.f, Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, , Haukeland University Hospital, ; Bergen, Norway

[4 ]ISNI 0000 0004 1936 7443, GRID grid.7914.b, Department of Clinical Medicine (K1), , University of Bergen, ; Bergen, Norway

[5 ]ISNI 0000 0000 9637 455X, GRID grid.411279.8, Health Services Research Unit, , Akershus University Hospital, ; Lørenskog, Norway

[6 ]ISNI 0000 0000 9637 455X, GRID grid.411279.8, Department of Data and Analytics, , Akershus University Hospital, ; Lørenskog, Norway

[7 ]ISNI 0000 0000 8567 2092, GRID grid.412285.8, Department of Sports Medicine, , Norwegian School of Sport Sciences, ; Oslo, Norway

Author information

Christian Thomas Pollmann http://orcid.org/0000-0002-3869-0129

Article

Publisher ID: 2637

DOI: 10.1186/s12891-019-2637-6

PMC ID: 6533651

PubMed ID: 31122228

SO-VID: dc9f1b51-fffc-4c13-83ea-316e33490d34

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 2 October 2018

Date accepted : 16 May 2019

Funding

Funded by: Sophies Minde AS, Oslo, Norway

Award ID: 06/2014

Award Recipient : Christian Thomas Pollmann

Funded by: Norwegian Orthopaedic Association/Heraeus Medical

Funded by: Akershus University Hospital

Custom metadata

ScienceOpen disciplines: Orthopedics

Keywords: hip fracture,fast track,mortality,reoperation,surgical site infection,admission time,time to surgery,length of stay,readmission,norwegian hip fracture register

Data availability:

ScienceOpen disciplines: Orthopedics

Keywords: hip fracture, fast track, mortality, reoperation, surgical site infection, admission time, time to surgery, length of stay, readmission, norwegian hip fracture register

Fast track hip fracture care and mortality – an observational study of 2230 patients

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Abstract

Background

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Trial registration

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Orthopedics

Most cited references 24

Early mortality after hip fracture: is delay before surgery important?

Predictors of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients.

Similar mortality rates in hip fracture patients over the past 31 years

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