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.     

Oral Regimens Also Found Effective for Subacute Bacterial Endocarditis

Abstract

Hip fracture is an unfortunate and common health problem in the elderly that is associated with a 1-year mortality of 10% to 35%. Further, only 50% of these patients regain their pre-fracture level of mobility and functional status. Hospital-based clinicians are increasingly asked to comanage these patients. The purpose of this article is to summarize evidence-based clinical management practices that are relevant to hospitalist clinicians who manage hip fracture patients, and to highlight the current evidence for implementing a formal hospitalist and orthopedic comanagement care model.     

Restoring control: empowering older patients and their families during health crisis.

Acute health crises and the care provided within the health care system often reduce control for older patients and their families. Drawing on the authors' research with hip fracture patients and work with home health teams, the discussion focuses specifically on older patients who require home health care following a hip fracture and who have family support. Successful recovery and rehabilitation of the older patient is contingent upon restoring the patients' perception of control over their recovery. Empowerment is achieved both through the content of interventions, and through the process by which health professionals work with patients and their families.     

Predictors of mortality and institutionalization after hip fracture: the New Haven EPESE cohort. Established Populations for Epidemiologic Studies of the Elderly.

OBJECTIVES. Hip fractures can have devastating effects on the lives of older individuals. We determined the frequency of occurrence of hip fracture and the baseline factors predicting death and institutionalization at 6 months after hip fracture. METHODS. A representative cohort of 2812 individuals aged 65 years and older was followed prospectively for 6 years. Hip fractures were identified, and the occurrence of death and institutionalization within 6 months of the fracture was determined. Prefracture information on physical and mental function, social support, and demographic features and in-hospital data on comorbid diagnoses, fracture site, and complications were analyzed to determine predictors of death and institutionalization after hip fracture. RESULTS. Of 120 individuals suffering a hip fracture, 22 (18%) died within 6 months and 35 (29%) were institutionalized at 6 months. The predictors of death in multiple logistic regression included fracture site, a high number of comorbid conditions, a high number of complications, and poor baseline mental status. The primary predictor of institutionalization was poor baseline mental status. CONCLUSIONS. The frequency of death, institutionalization, and loss of function after hip fracture should prompt a reevaluation of the current approach to this problem.     

Determinants of recovery 12 months after hip fracture: the importance of psychosocial factors.

The independent contributions to recovery from hip fracture of psychosocial factors including depression, personality, social connectedness, and self-rated health were studied in 219 women age 59 and older (mean age 78.5) who were community dwelling prior to fracture. Initial assessments were conducted shortly after surgery and follow up assessments 2, 6, and 12 months later. By 12 months, 15 patients had died and 15 had entered a nursing home. Substantial declines in physical functioning though not psychosocial status were observed. Only 21 per cent (compared to 81 per cent prefracture) reported walking independently; fewer than 30 per cent had regained reported prefracture levels of physical function. The proportion with elevated depression scores at 12 months was 20 per cent, down from 51 per cent following surgery; 64 per cent rated their health excellent or good at 12 months, up from 43 per cent after surgery. Poor cognitive status and post-surgical self-rated health were predictive of mortality. Among survivors, age, prefracture physical functioning, and cognitive status were associated with recovery in physical function but not psychosocial status. High post-surgery depression scores, but not the other psychosocial factors, were associated with poorer recovery in both functional and psychosocial status. These findings demonstrate the importance of depressive symptoms as one determinant of recovery from hip fracture and support the need to attend to the affective status of hip fracture patients following surgery.     

Hip fracture management for the hospital-based clinician: a review of the evidence and best practices

Hip fracture is an unfortunate and common health problem in the elderly that is associated with a 1-year mortality of 10% to 35%. Further, only 50% of these patients regain their pre-fracture level of mobility and functional status. Hospital-based clinicians are increasingly asked to comanage these patients. The purpose of this article is to summarize evidence-based clinical management practices that are relevant to hospitalist clinicians who manage hip fracture patients, and to highlight the current evidence for implementing a formal hospitalist and orthopedic comanagement care model.     

Cohort study of risk of institutionalisation after hip fracture

Abstract: The purpose of this study was to describe the rate of permanent placement in aged care institutions (nursing homes and hostels) after hip fracture and to assess whether or not hip fracture is an independent risk factor for institutionalisation. It was a cohort study with median follow-up time of 14 months. Subjects were 291 people living in the community in western Sydney: 131 with hip fractures and 160 controls. Permanent admission to an aged care institution and/or death during follow-up was assessed by telephone interview with study subjects or carers. Data on potential confounders were collected with an interviewer-administered questionnaire at the time of recruitment into the study. During follow-up, 27 per cent of hip fracture cases and 5 per cent of controls were admitted to an aged care institution. The age-and sex-adjusted hazard ratio for hip fracture and institutionalisation was 5.1 (95 per cent confidence interval (CI) 2.2 to 11.9). Adjusting for multiple health-related factors reduced the strength of association but the hazard ratio remained high at 4.0 (CI 1.7 to 9.5). The risk of institutionalisation after hip fracture is high; this is only partly explained by the poor pre-fracture health status of many people who fracture their hips.     

Psychosocial Correlates of Health Literacy Among Older Patients With Coronary Heart Disease

This study examined psychosocial correlates of health literacy (HL) scores among older patients with coronary heart disease (CHD). A cross-sectional survey assessed psychosocial factors relating to the following: self-efficacy (i.e., perception of ability to perform a specified behavior) for diet, exercise, medication, and for a future attempt to quit smoking; social support; social stigma; appointment attendance; knowledge of heart problems; and understanding of health information. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM). Of 321 patients, 70 had a REALM score in the low HL range (<60). When adjusting for demographics, a lower REALM score was significantly associated with reports of increased difficulty understanding health information (p < .001), less knowledge of heart problems (p = .002), increased discomfort about asking for explanations of health information (p = .014), less support with discussing health problems (p = .020). Patients with CHD and low HL are likely to face psychosocial challenges when managing their health problems. In order to encourage these individuals to seek help, health professionals need to be aware of the psychosocial characteristics of patients with low HL. These individuals may need behavioral support to increase both their self-efficacy and their understanding of their medical condition.     

Finding meaning after the fall: injury narratives from elderly hip fracture patients.

Hip fractures occur frequently among the elderly, often with severe medical, psychological and social repercussions. This research takes a new look at hip fracture rehabilitation, focusing on meanings and post-fracture prognostic indicators. An innovative methodological approach to narrative analysis is employed which combines ethnographic and epidemiologic techniques. Analyses of injury narratives from 80 elderly subjects interviewed soon after initial hospitalization are presented, focusing on three categories of meaning: explanatory models, sense of disability, and futurity. Insights from these narratives, as well as from questionnaires and observations, shed light on the experience of hip fracture for the elderly. In addition, aspects of the initial narratives are considered in relation to ambulation outcomes at 3 and 6 months. Those individuals who perceive their problem in a more external or mechanical fashion (caused by the environment) show greater improvement in ambulation at 3 and 6 months relative to those who show no evidence of this thinking or who perceive it as an internal or organic problem (in terms of disease or illness). Greater improvement in ambulation at 3 and 6 months is also noted for subjects whose perception of disability was consistent with more autonomy, independence, and a sense of connection with the world around them. The present study demonstrates the potential utility of narrative analysis as a data reduction approach. It also suggests the possibility of new psychosocial prognostic factors for hip fracture rehabilitation.     

Direct healthcare costs of osteoporosis-related fractures in managed care patients receiving pharmacological osteoporosis therapy

Background

Osteoporosis is a common condition and the economic burden of osteoporosis-related fractures is significant. While studies have reported the incremental or attributable costs of osteoporosis-related fracture, data on the economic impact of osteoporosis-related fractures in commercial health plan populations are limited.

Objective

To estimate the direct costs of osteoporosis-related fractures among pharmacologically treated patients in a large, commercially insured population between 2005 and 2008.

Methods

In this retrospective cohort study, patients were identified from a large, commercially insured population with integrated pharmacy and medical claims. Inclusion criteria were age 45?C64 years; one or more osteoporosis medication claim(s) with first (index) claim between 1 January 2005 and 30 April 2008; and continuous insurance coverage for ??12 months pre-index and ??6 months post-index. Patients with pre-index Paget??s disease or malignant neoplasm; skilled nursing facility stay; combination therapy at index; or fracture ??6 months post-index were excluded. A generalized linear model compared differences in 6-month pre-/post-event costs for patients with and without fracture. Propensity score weighting was used to ensure comparability of fracture and non-fracture patients. Generalized estimating equations accounted for repeated measures.

Results

The study included 49 680 patients (2613 with fracture) with a mean (SD) age of 56.4 (4.7) years; 95.9% were female. Mean differences between pre- and post-event direct costs were $US14049 (95% CI 7670, 20 428) for patients with vertebral fractures, $US16 663 (95% CI 11690, 21636) for patients with hip fractures, and $US7582 (95% CI 6532, 8632) for patients with other fractures. After adjusting for covariates, osteoporosis-related fractures were associated with an additional $US9996 (95% CI 8838, 11154; p< 0.0001) in direct costs per patient across all fracture types during the 6 months following fracture.

Conclusion

Patients with osteoporosis-related fractures were found to incur nearly $US10 000 in estimated additional direct healthcare costs in the 6 months post-fracture, compared with patients with no fracture. Reduced fracture risk may lower associated direct healthcare costs.