Determinants of Mortality After Hip Fracture Surgery in Sweden: A Registry-Based Retrospective Cohort Study

 
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Rasmus Åhman,
 
Pontus Forsberg Siverhall,
Johan Snygg,
 
Mats Fredrikson,
 
Gunnar Enlund,
Karin Björnström, 
Michelle S Chew
 
 
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Hip fractures are associated with
increased mortality, morbidity and
financial burden for patients and
health care providers.
1
Sweden has one of the highest age-
adjusted incidence of hip fractures in
the world
2-4. 
16.000 in the year 2017.
The number is predicted to double
between 2002 and 2050.
5
 
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Outcome after hip fracture surgery is
likely to be multifactorial.
Few studies have evaluated the entire
perioperative course including patient,
surgical, anaesthetic and structural
factors.
In addition, longer-term outcomes are
less frequently reported.
 
S
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This is a registry-based retrospective
cohort study using prospectively
collected data in the Swedish
PeriOperative Registry (SPOR). Patients
18 years of age with a Swedish social
security number undergoing surgical hip
fracture procedures between 1
st
 of
January 2014 and 31
st
 of December 2016
were included
 
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2
 
The exposures were a series of patient, surgery,
anaesthesia and structural factors in patients
subjected to acute hip fracture surgery.
 
All cause-mortality at longest follow-up was our
primary outcome.
Mortality data was extracted from the SPOR and
cross-checked with the Swedish Registry of
Deaths.
 
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age,
gender,
ASA-PS-class,
university hospital
status,
time of surgery,
type of surgery
 
compliance to
surgical urgency
planning,
 surgical delay,
 time in theatre,
 type of anaesthesia,
 PACU-LOS and
 ICU-admission
 
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SPOR was queried for all surgical
procedures with procedural codes
using the Swedish version of the
NOMESCO Classification of
Surgical Procedures.
33
KVÅ-codes in Swedish
 
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NFJ.XX (surgery for hip fractures) or
 NFB.XX (hip prosthetic surgery) in
combination with a primary
diagnosis of hip fractures
(diagnosis codes S72.XX).
 
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Patients who only had surgical
resetting codes (NFJ09 and NFJ19)
without secondary surgical procedural
codes
Patients undergoing elective surgery,
Patients without mortality data.
 
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SPOR is a prospectively maintained
registry with a number of built-in data
validation processes. For example, the
data are subject to a number of
automatic logical controls.
Incorrect and/or inconsistent posts are
returned to the user for correction prior
to inclusion in the database.
 
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Variables were checked for completeness and
consistency. Data regarding ASA-PS-class was
missing for 799 patients, PACU-LOS for 1310
patients and anesthetic technique for 231
patients.
We could not identify data that were obviously
missing in a systematic fashion, therefore all
14932 patients were included for analysis and
missing data were imputed.
 
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  General 2613 (17.8)
  Loco regional 12088 (82.2)
 
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1
 
To test for generalizability of results, sensitivity
analyses were performed for each calendar year.
Our sample size for 2014, 2015 and 2016 were
3202 patients (21.5%), 5188 patients (34.7%) and
6542 patients (43.8%) respectively.
The differences may be explained by the fact that
SPOR is a newly developed registry and coverage
increased over the 3 years.
 
C
o
n
c
l
u
s
i
o
n
 
1
 
Age, gender, ASA-PS-class were strong
predictors of mortality after surgery for
hip fractures in Sweden.
 
University hospital status and length of
stay in the postoperative care unit were
also identified as important modifiable
risk factors that persisted after
adjustment for confounders.
 
C
o
n
c
l
u
s
i
o
n
 
2
 
Whilst we are unable to attribute
causality to these findings, they
deserve attention in future studies
Study to help understand how
university hospital status and
postoperative care may contribute to
survival.
 
T
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SPOR home page: www.spor.se
 
A
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+,*
Rasmus Åhman
1
   
+
Pontus Forsberg Siverhall
1
+
Johan Snygg
2
   
Mats Fredrikson
3
Gunnar Enlund
4
   
Karin Björnström
1
Michelle S Chew
1
+
Rasmus Åhman, Pontus Forsberg Siverhall and Johan Snygg contributed equally to this
work
*Rasmus Åhman is corresponding author for this paper, 
rasah694@student.liu.se
**Michelle S Chew and Karin Björnström are co-senior authors
1
Department of Anaesthesia and Intensive Care, Department of Medical and Health
Sciences, Linköping University, Linköping, S-581 85 Sweden
2
Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 413 45
Gothenburg, Sweden
3
Department of Clinical and Experimental Medicine, Faculty of Medicine and Health,
Linköping University, S-581 85 Linköping, Sweden
4
Department of Anaesthesia and Intensive Care, Uppsala University Hospital, 781 85
 Uppsala, Sweden
 
 
 
+,*
Rasmus Åhman
1
+
Pontus Forsberg Siverhall
1
+
Johan Snygg
2
Mats Fredrikson
3
Gunnar Enlund
4
Karin Björnström
1
Michelle S Chew
1
+
Rasmus Åhman, Pontus Forsberg Siverhall and Johan Snygg contributed equally to this work
*Rasmus Åhman is corresponding author for this paper,
 
rasah694@student.liu.se
**Michelle S Chew and Karin Björnström are co-senior authors
1
Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Linköping
University, Linköping, S-581 85 Sweden
2
Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 413 45
Gothenburg, Sweden
3
Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Linköping
University, S-581 85 Linköping, Sweden
4
Department of Anaesthesia and Intensive Care, Uppsala University Hospital, 781 85
 Uppsala, Sweden
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Hip fractures in Sweden pose significant challenges due to increased mortality rates. A retrospective cohort study analyzed data from the Swedish PeriOperative Registry to identify factors influencing patient outcomes post-surgery, highlighting the importance of various perioperative variables on long-term mortality.


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  1. Determinants of mortality after hip fracture surgery in Sweden: a registry-based retrospective cohort study Rasmus hman,Pontus Forsberg Siverhall, Johan Snygg,Mats Fredrikson,Gunnar Enlund, Karin Bj rnstr m, Michelle S Chew

  2. Publicerades 2018-10-24

  3. Introduction 1 Hip fractures are associated with increased mortality, morbidity and financial burden for patients and health care providers.1 Sweden has one of the highest age- adjusted incidence of hip fractures in the world2-4. 16.000 in the year 2017. The number is predicted to double between 2002 and 2050.5

  4. Introduction 2 Outcome after hip fracture surgery is likely to be multifactorial. Few studies have evaluated the entire perioperative course including patient, surgical, anaesthetic and structural factors. In addition, longer-term outcomes are less frequently reported.

  5. Study design 1 This is a registry-based retrospective cohort study using prospectively collected data in the Swedish PeriOperative Registry (SPOR). Patients 18 years of age with a Swedish social security number undergoing surgical hip fracture procedures between 1stof January 2014 and 31stof December 2016 were included

  6. Study design 2 The exposures were a series of patient, surgery, anaesthesia and structural factors in patients subjected to acute hip fracture surgery. All cause-mortality at longest follow-up was our primary outcome. Mortality data was extracted from the SPOR and cross-checked with the Swedish Registry of Deaths.

  7. We investigated 12 independent variables that were a priori defined. compliance to surgical urgency planning, surgical delay, time in theatre, type of anaesthesia, PACU-LOS and ICU-admission age, gender, ASA-PS-class, university hospital status, time of surgery, type of surgery

  8. Data Collection 1 SPOR was queried for all surgical procedures with procedural codes using the Swedish version of the NOMESCO Classification of Surgical Procedures.33 KV -codes in Swedish

  9. Data Collection 2 Inclusions NFJ.XX (surgery for hip fractures) or NFB.XX (hip prosthetic surgery) in combination with a primary diagnosis of hip fractures (diagnosis codes S72.XX).

  10. Data Collection 3 Exclusions Patients who only had surgical resetting codes (NFJ09 and NFJ19) without secondary surgical procedural codes Patients undergoing elective surgery, Patients without mortality data.

  11. Figure 1: Flowchart demonstrating the inclusion process.

  12. Data collection and cleaning 1 SPOR is a prospectively maintained registry with a number of built-in data validation processes. For example, the data are subject to a number of automatic logical controls. Incorrect and/or inconsistent posts are returned to the user for correction prior to inclusion in the database.

  13. Data collection and cleaning 2 Variables were checked for completeness and consistency. Data regarding ASA-PS-class was missing for 799 patients, PACU-LOS for 1310 patients and anesthetic technique for 231 patients. We could not identify data that were obviously missing in a systematic fashion, therefore all 14932 patients were included for analysis and missing data were imputed.

  14. ldersgrupper / Age groups 90 85-89 80-84 70-79 55-69 18-54 0 500 1000 1500 2000 2500 3000 3500 4000

  15. Cox analys , Univariable analysis, associated with 30 day mortality.

  16. ASA-class mean 2,60 ASA 5 ASA 4 ASA 3 ASA 2 ASA 1 0 1000 2000 3000 4000 5000 6000 7000 8000

  17. Cox analys , Univariable analysis, associated with 30 day mortality.

  18. Type of surgical procedure Hip replacement: non-cemented Hip replacement: cemented Osteosynthesis: screw and plate Osteosynthesis: intramedullary nail Osteosynthesis: cerclage, spikes, pins 0 1000 2000 3000 4000 5000 6000

  19. Type of syurgery does not matter

  20. Surgical planning waiting time >24h <24h <6h <2h <0.5h (emergency) 0 2000 4000 6000 8000 10000 12000 14000

  21. Surgical waiting time no difference!

  22. Surgery - Time of day no extra risk

  23. Anaesthetic technique no difference in mortality30 days General 2613 (17.8) Loco regional 12088 (82.2)

  24. Lengths of stay at PACU matters, p=<0,001

  25. Other results: 30-day mortality 365-day mortality = 8,2% = 23,6 %

  26. University hospitals perform better

  27. Sensitivitetstest 1 To test for generalizability of results, sensitivity analyses were performed for each calendar year. Our sample size for 2014, 2015 and 2016 were 3202 patients (21.5%), 5188 patients (34.7%) and 6542 patients (43.8%) respectively. The differences may be explained by the fact that SPOR is a newly developed registry and coverage increased over the 3 years.

  28. Conclusion 1 Age, gender, ASA-PS-class were strong predictors of mortality after surgery for hip fractures in Sweden. University hospital status and length of stay in the postoperative care unit were also identified as important modifiable risk factors that persisted after adjustment for confounders.

  29. Conclusion 2 Whilst we are unable to attribute causality to these findings, they deserve attention in future studies Study to help understand how university hospital status and postoperative care may contribute to survival.

  30. Take a walk with SPOR! SPOR home page: www.spor.se

  31. Authors +,*Rasmus hman1 +Johan Snygg2 Gunnar Enlund4 Michelle S Chew1 +Pontus Forsberg Siverhall1 Mats Fredrikson3 Karin Bj rnstr m1 +Rasmus hman, Pontus Forsberg Siverhall and Johan Snygg contributed equally to this work *Rasmus hman is corresponding author for this paper, rasah694@student.liu.se **Michelle S Chew and Karin Bj rnstr m are co-senior authors 1Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Link ping University, Link ping, S-581 85 Sweden 2Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden 3Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Link ping University, S-581 85 Link ping, Sweden 4Department of Anaesthesia and Intensive Care, Uppsala University Hospital, 781 85 Uppsala, Sweden

  32. +,*Rasmus hman1 +Pontus Forsberg Siverhall1 +Johan Snygg2 Mats Fredrikson3 Gunnar Enlund4 Karin Bj rnstr m1 Michelle S Chew1 +Rasmus hman, Pontus Forsberg Siverhall and Johan Snygg contributed equally to this work *Rasmus hman is corresponding author for this paper, rasah694@student.liu.se **Michelle S Chew and Karin Bj rnstr m are co-senior authors 1Department of Anaesthesia and Intensive Care, Department of Medical and Health Sciences, Link ping University, Link ping, S-581 85 Sweden 2Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden 3Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Link ping University, S-581 85 Link ping, Sweden 4Department of Anaesthesia and Intensive Care, Uppsala University Hospital, 781 85 Uppsala, Sweden

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