D. Fluck1, C.H. Fry2, R. Lisk3, K. Yeong3, J. Robin4, T.S. Han5,6
1. Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK; 2. School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK; 3. Department of Orthogeriatrics, Ashford and St Peter’s NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK;
4. Department of Acute Medicine, Ashford and St Peter’s NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK; 5. Department of Endocrinology, Ashford and St Peter’s NHS Foundation Trust, Guildford Road, Chertsey, Surrey KT16 0PZ, UK; 6. Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, Surrey TW20 0EX, UK
Corresponding Author: Dr Thang S Han, Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, Surrey, TW20 0EX, UK. Tel: 01784443807, Email: firstname.lastname@example.org
J Frailty Aging 2022;in press
Published online May 16, 2022, http://dx.doi.org/10.14283/jfa.2022.34
Background: There is increasing interest in healthcare quality and economic implications for hip fracture patients of very old age. However, results are limited by access to comparable control groups.
Objectives: We examined healthcare quality measures including mortality and length of stay (LOS) in hospital of adults aged 60-107 years undergoing hip operations, compared to an age-matched group admitted for acute general medical conditions.
Design: Monocentric cross-sectional study.
Setting: Ashford and St Peter’s Hospitals NHS Foundation Trust, Surrey, United Kingdom.
Participants: A total of 3972 consecutive admissions for hip operation from 1st April 2009 to 30th June 2019 (dataset-1) and 6979 for acute general medical conditions from 1st April 2019 to 29th February 2020 (dataset-2). Respective ages, mean (±standard deviation), were 83.5 years (±9.1) and 79.8 years (±9.8).
Measurements: Mortality and LOS were assessed with each group divided into five- year age bands and those ≥95 years.
Results: There were proportionally more (P <0.001) females admitted for hip operations (72.8%) than for acute general medical conditions (53.8%). Amongst patients admitted with general medical conditions, the frequency of the most serious recorded conditions – including congestive heart failure, stroke, and pneumonia – increased with age. Amongst patients undergoing hip operations, 5.7% died in hospital and 29.3% had a LOS ≥3 weeks. Corresponding values for acute general medical conditions were 10.4% and 11.8%. For those undergoing hip operations in all age categories, the risk of death was lower than for acute general medical group: sex-adjusted odds ratios ranged between 0.27 and 0.67, but the risk of LOS ≥3 weeks was greater: odds ratios ranged between 2.46 and 2.95.
Conclusions: Compared to those admitted with acute general medical conditions, patients admitted for hip operations had a lower risk of death, but a longer hospital LOS.
Key words: Geriatrics, health economics, discharge planning, healthcare quality.
In high income countries the population age profile in favour of older adults has been changing over the past five decades. In the UK, the greatest increase is in those over 85 years. In 2016, there were 1.6 million people aged above 85 years (2% of the total population); by 2041 this is projected to reach 3.2 million, rising further to 5.1 million by 2066 (7% of the total population) (1). Older age is associated with greater overall frailty and frequent falls and one of the biggest causes of hospital admissions in the older adult is from hip fractures due to falls. Because of this rising incidence, in both sexes (2), there are currently more people than ever living with the consequences of a hip fracture (3, 4). This life-changing event can result in disability requiring a high level of care, including a lengthy stay in hospital; as well as premature death, including before hospital discharge (5-8).
There is an increasing interest in the impact of hip fractures on an ageing population of patients, particularly those older than 90 years of age, and the implications for improving care with disability, survival and consequences for health economics (9-13). Hitherto, results from previous studies have been limited due to the smaller number of very old patients, so that these studies accumulated data from different centres where management procedures may differ (13). More crucially, younger patients have been used as control groups where comparisons may be inappropriate (9, 10, 14). In this study, indicators of care-quality, including in-hospital length of stay (LOS) and mortality, were compared between patients admitted for hip operations and those admitted with acute general medical conditions. An age-stratified analysis was used to include examination of very old age (≥90 years) patients who were admitted to a single National Health Service (NHS) hospital.
Study design, participants and setting
This a cross-sectional study of older (≥60 years) patients admitted to Ashford and St Peter’s Hospitals NHS Foundation Trust, Surrey, United Kingdom, comprising two datasets. Dataset-1 contains 3972 consecutive admissions between 1st April 2009 and 30th June 2019 for hip fracture operations, and dataset-2 contains 6979 patients admitted between 1st April 2019 and 29th February 2020 with acute general medical conditions. The two datasets were compared for LOS and mortality.
Data for every patient admitted with a hip fracture were collected through our participation in the National Hip Fracture Database (15, 16). Data for all unplanned admissions with acute general medical conditions were collected in accordance with NHS guidelines, and were recorded by the Patient Administration System (17, 18). For the purpose of this study, only adults admitted with acute general medical conditions aged ≥60 years were included to match those admitted for a hip operations.
Categorisation of data
Prolonged LOS was defined as hospitalization of ≥3 weeks. Age categories were created for every five-year age band from 60 years, except all those aged ≥95 years were considered as one category due to their relatively small number.
Differences between categorical outcome variables were assessed by χ2-tests. Differences in LOS between two groups and between multiple sub-groups were assessed by Mann-Whitney U tests and by Kruskal-Wallis tests, respectively. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) of outcome measures between patients undergoing hip operations and those admitted with acute general medical conditions (reference group). The results are presented from two models; model 1 – unadjusted; model 2 – adjusted for sex. Analyses were conducted using IBM SPSS Statistics, v25.0 (IBM Corp., Armonk, NY).
The mean (±SD) ages of the two groups were not significantly different (P >0.05) and were: 83.5 years (±9.1) for those requiring hip operations and 79.8 years (±9.8) for those with acute general medical conditions. Amongst patients undergoing a hip operation, there were 5.7% who died and 29.3% had a LOS ≥3 weeks in hospital; the corresponding values for those admitted with acute general medical conditions were 10.4% and 11.8%.
However, the age profiles of the two groups were different; there were greater percentages in the four highest age groups (i.e. those ≥80 years of age) for those requiring hip operations compared to those in the acute general medical conditions cohort (Table 1). In particular, 37 patients undergoing hip operations were over 100 years of age (0.9% of the total) as were 41 patients admitted with acute medical conditions (0.6% of the total). There were proportionally more (P <0.001) females admitted for hip operations (72.8%) than for acute general medical conditions (53.8%).
*Maximum age = 107 years, including 37 centenarians in dataset 1, and 41 centenarians in dataset 2.
Amongst patients admitted with general medical conditions, the frequency of the most serious recorded conditions – including congestive heart failure, stroke, and pneumonia – increased with age, except for acute myocardial infarction, which decreased with age (Table 2). These conditions were associated with higher rates of mortality in this study group (Figure 1).
Comparison of in-hospital mortality
Rates of in-hospital mortality were consistently lower within each age band amongst patients who were admitted for hip operations compared to those admitted with acute general medical conditions. Both study groups showed significantly increasing trends of mortality with age: P <0.001 (Figure 2). Logistic regression showed the risk of mortality in hospital was lower for those admitted for a hip operation: the sex-adjusted OR ranged between 0.27 and 0.67 (Table 3).
Comparison of length of stay in hospital
The LOS in hospital increased significantly with age in both groups of patients (Kruskal-Wallis tests: P <0.001). Moreover, within each age band the LOS in hospital was longer for patients admitted for a hip operation than those admitted with acute general medical conditions (Mann-Whitney U tests: P <0.001). Amongst the eight groups of every five-year band from 60 to ≥95 years, the median (interquartile range) values for LOS of patients undergoing hip operations were 7.9 (4.1-13.1), 9.4 (5.7-15.5), 10.1 (7.1-16.7), 11.6 (7.3-22.9), 13.4 (8.4-23.2), 15.1 (9.2-24.8), 15.2 (9.4-26.9), and 16.2 (10.1-28.5) – Figure 3A. The corresponding values for those with acute general medical conditions were: 1.3 (0-4.3), 1.5 (0-4.6), 2.1 (0.1-7.1), 3.0 (0.3-9.5), 4.8 (0.8-11.5), 6.3 (1.4-16.2), 6.9 (2.1-16.0), and 7.1 (2.0-14.3). Within each study group, LOS increased significantly with age (Kruskal-Wallis tests: P <0.001), and within each age band, LOS differed significantly between the two study groups (Mann-Whitney U tests: P <0.001: Figure 3A).
There were also higher proportions with prolonged LOS (≥3 weeks) with age in both study groups (Mantel-Haenszel tests: P <0.001; Figure 3B). Logistic regression also showed that the risk of prolonged LOS was greater for those admitted for hip operation in all age categories: sex-adjusted OR ranged between 2.46 and 2.95 (Table 3).
This study shows that for any given age from the age of 60 years patients undergoing hip operations stayed in hospital longer compared to those admitted with acute general medical conditions, but they had a lower risk of death. To the best of our knowledge, no previous studies have compared in a single centre care-quality measures of patients admitted for hip operation with respect to age-matched patients admitted with acute general medical conditions.
Surgery is important to an individual who has sustained a hip fracture to alleviate disability and be more likely to allow independent living (19-21). Our findings of a lower risk of mortality amongst those who underwent hip operations, compared to age-matched patients with acute general medical conditions, suggest that age is not a limiting factor to hip surgery. This is at variance to a common notion that older individuals undergoing surgery for hip fractures are at increased risk of death. Previous studies did not include a comparator group (11-13), or used incompatible control groups, such as those comprising younger patients (9, 10, 14). Some studies also compared mortality with standardised mortality of the general population (22, 23). Our findings of increasing adverse outcomes with age in either study group were, however, consistent with previous observations (9, 10, 14, 17, 18). The higher proportion of females to males is also similar to previous studies of hip fracture patients (24, 25). Two important and novel findings have thus emerged from our study. Firstly, for a given age, mortality rates amongst patients admitted for hip operations were lower than those admitted with acute general medical conditions. Secondly, these differences were constant across all ages. These patterns were also observed with respect to prolonged LOS.
The present study included a relatively large number of older individuals over 80 years. Previous figures have reported 0.7% of total patients admitted for hip operations were centenarians (26) compared to 0.9% in this study. The group of 37 centenarians undergoing hip operations in our study was one of the highest reported for a single centre. However, even with this number, it is difficult to obtain meaningful statistical results and we therefore combined all those over 95 years into the oldest age band.
The lower rates of mortality amongst patients admitted for hip operations than those admitted with acute general medical conditions is novel. This variance may indicate differences of underlying patient health; worse in those admitted with acute general medical conditions. It is possible that the higher mortality rates amongst patients admitted with general medical conditions could be explained by their primary diagnosis presented at admission including acute myocardial infarct, congestive heart failure, stroke and pneumonia. These conditions can have more serious acute pathologies in older patients than those undergoing an operation for a hip fracture. An alternative explanation may be due to the management of patients undergoing hip fracture surgery who are under the care of a multidisciplinary team of orthogeriatricians and orthopedic surgeons and who receive more detailed assessment with early management of pain, nutrition and mobilisation (16, 27).
Patients admitted with a hip operation stayed in hospital longer than those with acute general medical conditions. The median LOS amongst the oldest age bands was 16 days, shorter than previous observations by Holt et al who reported 26 days for those over 95 and 25 days for those of younger age (10). We have recorded in our previous studies that 25% of all patients admitted for hip operation were transferred to rehabilitation and 4.5% were a new referral to a care home (16). These factors could have an impact on LOS in a number of ways. On the one hand, discharge may be delayed whilst waiting for a rehabilitation place or for nursing care, thus they would have a longer LOS. Alternatively, once a place in rehabilitation is secured, early discharge support is more readily available. Since LOS increased with age for both studies, the relative differences in LOS, or risk of prolonged LOS (≥3 weeks), between the two groups were similar for all ages, including those in very old age groups.
The strengths of this study lie in its relatively large number of patients derived from a single NHS hospital that serves a population of >400,000 people. There were certain limitations including the time frames over which data were collected, where the majority of patients requiring a hip operation were admitted at earlier times than those admitted with acute general medical conditions. The management of hip fracture patients has improved over the past decade (16), so that their favourable care-quality indicators observed in this study might have been underestimated. Our findings may be biased by the use of patients with acute general medical conditions as a reference group, but we were able to eliminate age as a variable, which has not been performed in previous studies. However, caution should be taken when interpreting our findings, particularly with respect to LOS, which could be influenced by different discharge pathways between patients with hip fractures and those with acute general medical conditions. Ideally, further analysis of discharge destinations (own home or nursing/ residential care) should be conducted to compare LOS between these two study groups.
In conclusion, compared to those admitted with acute general medical conditions, patients admitted for hip operations had a longer LOS in hospital, but a lower risk of death. However, for both variables these differences were independent of age, including patients over 90 years of age. Our findings suggest that it is safe for individuals of very old age to undergo hip surgery, and so alleviate any disability to improve their independence and quality of life.
Contributions: TSH and DF reviewed the topic related literature and performed the study concept and analysis design. RL, KY, JR and DF performed the study coordination and data collection and commented on the manuscript. TSH wrote the first draft, analysed, interpreted the data and revised the manuscript. CHF edited the manuscript. All authors checked, interpreted results and approved the final version.
Ethical approval: This study does not require NHS Research Ethics Committee approval since it involves secondary analysis of anonymised data. This study was conducted in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Statement of human and animal rights: This article does not contain any studies with animals performed by any of the authors. Informed consent Informed consent was obtained from all individual participants included in the study.
Conflict of interest: David Fluck, Christopher H Fry, Radcliffe Lisk, Keefai Yeong, Jonathan Robin, and Thang S Han declare that they have no conflicts of interest.
Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as 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.
1. Office for National Statistics. www.ons.gov.uk/peoplepopulationand community/birthsdeathsandmarriages/ageing/articles/livinglonger howourpopulationischangingandwhyitmatters/2018-08-13 (Accessed Jan 20, 2022).
2. Curtis EM, van der Velde R, Moon RJ, van den Bergh JP, Geusens P, de Vries F, et al. Epidemiology of fractures in the United Kingdom 1988–2012: variation with age, sex, geography, ethnicity and socioeconomic status. Bone. 2016;87:19-26. doi: 10.1016/j.bone.2016.03.006
3. Court-Brown CM, McQueen MM. Global forum: fractures in the elderly. JBJS. 2016;98(9):e36. doi: 10.2106/jbjs.15.00793
4. Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458-60. doi: 10.1016/j.injury.2018.04.015
5. Bliuc D, Alarkawi D, Nguyen TV, Eisman JA, Center JR. Risk of subsequent fractures and mortality in elderly women and men with fragility fractures with and without osteoporotic bone density: the Dubbo Osteoporosis Epidemiology Study. J Bone Miner Res. 2015;30(4):637-46. doi: 10.1002/jbmr.2393
6. Sullivan KJ, Husak LE, Altebarmakian M, Brox WT. Demographic factors in hip fracture incidence and mortality rates in California, 2000–2011. J Orthop Surg Res. 2016;11(1):1-0. doi: 10.1186/s13018-015-0332-3
7. Papadimitriou N, Tsilidis KK, Orfanos P, Benetou V, Ntzani EE, Soerjomataram I, et al. Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium. Lancet Public Health. 2017;2(5):e239-46. doi: 10.1016/s2468-2667(17)30046-4
8. Lisk R, Uddin M, Parbhoo A, Yeong K, Fluck D, Sharma P, et al. Predictive model of length of stay in hospital among older patients. Aging Clin Exp Res. 2019;31(7):993-9. doi: 10.1007/s40520-018-1033-7
9. Oliver CW, Burke C. Hip fractures in centenarians. Injury. 2004;35(10):1025-30. doi: 10.1016/j.injury.2003.10.004
10. Holt G, Smith R, Duncan K, Hutchison JD, Gregori A. Outcome after surgery for the treatment of hip fracture in the extremely elderly. JBJS. 2008;90(9):1899-905. doi: 10.2106/jbjs.g.00883
11. Tarity TD, Smith EB, Dolan K, Rasouli MR, Maltenfort MG. Mortality in centenarians with hip fractures. Orthopedics. 2013;36(3):e282-7. doi: 10.3928/01477447-20130222-15
12. Dick AG, Davenport D, Bansal M, Burch TS, Edwards MR. Hip fractures in centenarians: has care improved in the national hip fracture database era?. Geriatr Orthop Surg Rehabil. 2017;8(3):161-5. doi: 10.1177/2151458517722104
13. Barrett-Lee J, Barbur S, Johns J, Pearce J, Elliot RR. Hip fractures in centenarians: a multicentre review of outcomes. Ann R Coll Surg Engl. 2021;103(1):59-63. doi: 10.1308/rcsann.2020.0203
14. Miller AG, Bercik MJ, Ong A. Nonagenarian hip fracture: treatment and complications. J Trauma Acute Care Surg. 2012;72(5):1411-5. doi: 10.1097/ta.0b013e318246f3f8
15. Royal College of Physicians. The National Hip Fracture Database. Part of the Falls and Fragility Fracture Audit Programme. https://www.nhfd.co.uk/. (Accessed Jan 20, 2022)
16. Fluck B, Yeong K, Lisk R, Watters H, Robin J, Fluck D, et al. Changes in characteristics and outcomes of patients undergoing surgery for hip fractures following the initiation of orthogeriatric service: temporal trend analysis. Calcif Tissue Int. 2022;110(2):185-95. doi: 10.1007/s00223-021-00906-4
17. Heppleston E, Fry CH, Kelly K, Shepherd B, Wright R, Jones G, et al. LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge. Aging Clin Exp Res. 2021;33(4):1041-8. doi: 10.1007/s40520-020-01609-w
18. Fry CH, Heppleston E, Fluck D, Han TS. Derivation of age-adjusted LACE index thresholds in the prediction of mortality and frequent hospital readmissions in adults. Intern Emerg Med. 2020;15(7):1319-25. doi: 10.1007/s11739-020-02448-3
19. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008(3). doi: 10.1002/14651858.cd000337.pub2
20. Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: an evidence-based review of the literature. II: intertrochanteric fractures. J Am Acad Orthop Surg. 2008;16(11):665-73. doi: 10.5435/00124635-200811000-00007
21. Ooi LH, Wong TH, Toh CL, Wong HP. Hip fractures in nonagenarians – a study on operative and non-operative management. Injury. 2005;36(1):142-7. doi: 10.1016/j.injury.2004.05.030
22. Shah MR, Aharonoff GB, Wolinsky P, Zuckerman JD, Koval KJ. Outcome after hip fracture in individuals ninety years of age and older. J Orthop Trauma. 2001;15(1):34-9. doi: 10.1097/00005131-200101000-00007
23. Van de Kerkhove MP, Antheunis PS, Luitse JS, Goslings JC. Hip fractures in nonagenarians: perioperative mortality and survival. Injury. 2008;39(2):244-8. doi: 10.1016/j.injury.2007.07.009
24. Forster MC, Calthorpe D. Mortality following surgery for proximal femoral fractures in centenarians. Injury. 2000;31(7):537-9. doi: 10.1016/s0020-1383(00)00049-8
25. Haleem S, Lutchman L, Mayahi R, Grice JE, Parker MJ. Mortality following hip fracture: trends and geographical variations over the last 40 years. Injury. 2008;39(10):1157-63. doi: 10.1016/j.injury.2008.03.022
26. Manoli III A, Driesman A, Marwin RA, Konda S, Leucht P, Egol KA. Short-term outcomes following hip fractures in patients at least 100 years old. JBJS. 2017;99(13):e68. doi: 10.2106/jbjs.16.00697
27. Han TS, Lisk R, Osmani A, Sharmin R, El Gammel S, Yeong K, et al. Increased association with malnutrition and malnourishment in older adults admitted with hip fractures who have cognitive impairment and delirium, as assessed by 4AT. Nutr Clin Pract. 2021;36:1053-8. doi: 10.1002/ncp.10614