|Abstract / Summary
Patients sustaining a hip fracture face an increased mortality and readmission risk, often accompanied by functional decline that may lead to long-term institutionalization. Whereas most patients with hip fractures are frail, several subgroups exist. They range from healthy and active older patients living independently to comorbid and bedridden nursing home residents. Because of this heterogeneity, future treatment of hip fractures may aim to be related more to the patient than to the diagnosis. To achieve this, more information about patients at risk is required. Therefore, the overall aim of this dissertation was to investigate which hip fracture patients are at risk of poor outcomes and to identify targets for interventions. Furthermore, the dissertation aimed to assess the treatment currently provided. Such knowledge may help target future interventions and may thus potentially serve to improve the prognosis following a hip fracture.
Study I examined the overall adherence to seven best-practice indicators. Adherence was low, with only a third meeting the requirements of all seven indicators. The most dependent patients characterized by cognitive impairment, comorbidities, or low functional levels had a significantly lower adherence than the remaining patients. Among the individual indicators, not achieving preoperative pain management,
thromboprophylaxis, postoperative mobilization, and blood transfusions were associated with an increased mortality. None of the indicators were associated with readmission risk.
Studies II, III, and V investigated risk factors for poor outcomes. Unsurprisingly, the most dependent patients carried the highest risk in all
three studies. Even so, the studies established some modifiable risk factors that may potentially be targeted for interventions. In Study II, increased mortality was found for comorbid and malnourished patients, and patients operated on more than 36 hours after their admission or mobilized more than 24 hours after their surgery. In Study III, the most interesting results were that while delaying surgery for more than 36 hours increased readmission, no differences were found between patients delayed due to medical issues and organizational reasons. Furthermore, we investigated the impact of active clinical issues at discharge and found them to predict
readmissions, especially medical readmissions.
In Study V, mobilizing patients to standing within 24 hours from surgery was associated with achieving independence at discharge, which, in turn, was associated with return to independent living at 12 months.
Study IV compared intramedullary nails (IMN) to dynamic hip screws with trochanteric stabilizing plate in the treatment of unstable intertrochanteric fractures. Only minor differences were found, with increased blood loss and fewer patients mobilized within 24 hours in the IMN group. However, no differences were found regarding regaining prefracture function and patient-reported outcomes at one year, or reoperation rates within three years.
In conclusion, the most dependent patients carried a higher risk of obtaining a poorer outcome, and providing the best possible treatment was more challenging for this group than for other groups. Dividing patients into subgroups will be essential in future studies to investigate which treatment steps are more important for each particular subgroup and how to provide them. Such studies providing treatments that are more closely tailored to the individual patient may be key to achieving better outcomes. One place
to start based on the results presented in this dissertation may be to focus on hospital-related variables such as time to surgery, postoperative mobilization, and discharge planning including active clinical issues.