R. Smektala

Patients with femoral or distal forearm fracture in Germany: a prospective observational study on health care situation and outcome

BackgroundDistal radius and proximal femoral fractures are typical injuries in later life, predominantly due to simple falls, but modulated by other relevant factors such as osteoporosis. Fracture incidence rates rise with age. Because of the growing proportion of elderly people in Western industrialized societies, the number of these fractures can be expected to increase further in the coming years, and with it the burden on healthcare resources. Our study therefore assessed the effects of these injuries on the health status of older people over time. The purpose of this paper is to describe the study method, clinical parameters of fracture patients during hospitalization, mortality up to one and a half years after discharge in relation to various factors such as type of fracture, and to describe changes in mobility and living situation.MethodsData were collected from all consecutive patients (no age limit) admitted to 423 hospitals throughout Germany with distal radius or femoral fractures (57% acute-care, femoral and forearm fractures; 43% rehabilitation, femoral fractures only) between January 2002 and September 2003. Polytrauma and coma patients were excluded. Demographic characteristics, exact fracture location, mobility and living situation, clinical and laboratory parameters were examined. Current health status was assessed in telephone interviews conducted on average 6–7 months after discharge. Where telephone contact could not be established, at least survival status (living/deceased/date of death) was determined.ResultsThe study population consisted of 12,520 femoral fracture patients (86.8% hip fractures), average age 77.5 years, 76.5% female, and 2,031 forearm fracture patients, average age 67.6 years, 81.6% female. Womens average age was 6.6 (femoral fracture) to 10 years (forearm fracture) older than mens (p < 0.0001). Only 4.6% of femoral fracture patients experienced changes in their living situation post-discharge (53% because of the fracture event), although less than half of subjects who were able to walk without assistive devices prior to the fracture event (76.7%) could still do so at time of interview (34.9%). At time of interview, 1.5% of subjects were bed-ridden (0.2% before fracture). Forearm fracture patients reported no change in living situation at all. Of the femoral fracture patients 119 (0.95%), and of the forearm fracture patients 3 (0.15%) died during hospital stay. Post-discharge (follow-up one and a half years) 1,463 femoral fracture patients died (19.2% acute-care patients, 8.5% rehabilitation patients), but only 60 forearm fracture patients (3.0%). Ninety percent of femoral fracture deaths happened within the first year, approximately 66% within the first 6 months. More acute-care patients with a pertrochanteric fracture died within one year post-discharge (20.6%) than patients with a cervical fracture (16.1%).ConclusionMortality after proximal femoral fracture is still alarmingly high and highest after pertrochanteric fracture. Although at time of interview more than half of femoral fracture patients reported reduced mobility, most patients (96%) attempt to live at home. Since forearm fracture patients were on average 10 years younger than femoral fracture patients, forearm fractures may be a means of diagnosing an increased risk of later hip fractures.

Mediale Schenkelhalsfraktur: Einfluss des Versorgungszeitpunkts auf die Ergebnisqualität

PROBLEM According to international and national studies and clinical guidelines, patients with medial hip neck fracture should receive surgery as soon as medically reasonable after hospitalization, preferably within 48 h. Analysis of the German quality registry data of 2006 showed, however, that in 13 out of the 16 federal states less than 85% of patients were operated on within 48. Delayed surgery was found especially during the weekend. OBJECTIVE The objective of the study was to examine whether German data confirm that a short preoperative waiting time after hip fracture improves the outcome. The study was commissioned by the Federal Joint Committee (G-BA) and was jointly performed by the German Society for Accident Surgery (DGU) and the National Institute for Quality in Healthcare (BQS). DATA AND METHODS The analysis is based on the data of the nationwide quality registry of the years 2004-2006. Out of a total of 129,075 patients with a medial hip neck fracture 22,171 received operative treatment later than 48 h after hospital admission. Comparable study groups were constructed with the help of a propensity score (1-to-1 matching). Study and control groups only differed in terms of delay of surgery. The comparison concerning the outcomes was made with the Fisher exact test (bilateral). RESULTS In the group of patients with a delay of surgery longer than 48 h significantly higher rates of surgical complications (OR 1.10), general complications (OR 1.09) and pressure ulcers (1.27) were observed (all p<0.001). The in-hospital mortality showed no significant difference (OR 0.96, p=0.302). CONCLUSIONS Patients with medial hip neck fracture should receive operative treatment without delay, if no medical contra-indications for immediate surgery. In particular appropriate organizational measures should be taken to ensure an early surgical treatment even during weekends.

Die stationäre Behandlungsqualität der distalen Radiusfraktur in Deutschland

BACKGROUND This study is the first to document the quality of inpatient care provided to elderly patients with distal radius fracture in Germany. PATIENTS AND METHODS Inpatient care provided to 1,201 patients age 65 or older with isolated distal radius fracture was documented in a prospective cohort study conducted at 242 acute care clinics in Germany between January 2002 and September 2003. RESULTS The median patient age was 75, and nearly 90% of patients were female. Approximately 71% of patients were classified as ASA I or II, and 28% were ASA III. The most common comorbidity was arterial hypertension (60%). Seventy-five percent of patients were admitted on the day of the accident; of these, 63% had surgery on the same day, and 20% on the following day. The primary form of anaesthesia was general anaesthesia (55%). The predominant fracture management procedure was percutaneous K-wire osteosynthesis (56% of cases), followed by plate osteosynthesis (44%). The length of hospital stay after plate osteosynthesis (median 8.5 days) was more than twice as long as after K-wire osteosynthesis (median 4 days). The rate of postoperative complications typical of each procedure was around 10%. Roughly 90% of patients were discharged to home. Although evidence of osteoporosis was observed in 62% of women and 50% of men, only 7.9% of patients were prescribed osteoporosis-specific medication. CONCLUSIONS Unexpected findings were the predominance of general anaesthesia and percutaneous K-wire osteosynthesis. Osteoporosis, affecting a majority of elderly women, is neglected in clinical practice. Good quality of care is reflected by the low rate of complications.

Pertrochanteric fractures. What impact do surgical timing and implant choice have on the outcome

Pertrochanteric fractures are grouped together with femoral neck fractures to represent the most frequent femur fractures in the region of the hip joint and usually occur in elderly people with preexisting conditions. Analysis of the data from the 2004/2005 quality assurance program of North Rhine-Westphalia shows, just as is the case for medial femoral neck fractures, that not only does delayed management increase risk-adjusted general and surgical complications but also mortality.ZusammenfassungPertrochantäre Frakturen werden mit den Schenkelhalsfrakturen zu den hüftgelenknahen Femurfrakturen zusammengefasst und sind in der Regel Frakturen des älteren und vorerkrankten Menschen. Die Auswertung der QS-NRW-Daten 2004/2005 zeigt nicht nur, dass ebenso wie für die medialen Schenkelhalsfrakturen bei verzögerter Versorgung die risikoadjusiterten allgemeinen und chirurgischen Komplikationen sondern auch die Mortalität ansteigt.AbstractPertrochanteric fractures are grouped together with femoral neck fractures to represent the most frequent femur fractures in the region of the hip joint and usually occur in elderly people with preexisting conditions. Analysis of the data from the 2004/2005 quality assurance program of North Rhine-Westphalia shows, just as is the case for medial femoral neck fractures, that not only does delayed management increase risk-adjusted general and surgical complications but also mortality.

[Guideline compliance in hip fracture: results of an external quality-assurance program in North Rhine Westphalia: 2003-2005].

BACKGROUND Whereas the Scottish guidelines are audited annually, nobody evaluates guideline compliance in Germany. Thus, can external quality assurance data pursuant to section 137 of the German Social Code Book V be suitable for auditing guideline compliance? MATERIALS AND METHODS From North Rhine Westphalia, a total of 48,831 cases of femoral fractures near the hip joint were evaluated. Compliance with the guidelines was determined based on preoperative hospital stay, thrombosis, and antibiotic prophylaxis. Guideline rationale was reviewed in terms of mortality and thromboembolism rate. RESULTS Sixty-four percent of the interventions were performed in a timely manner. Thrombosis prophylaxis was given in 99% of cases. Antibiotics were given as a single shot. There was no connection between mortality and thromboembolism rates or time to surgery. CONCLUSION Guideline compliance is similar in German and Scotland. The external quality assurance data are suitable for evaluating guideline compliance. The literature recommends a short time to surgery. Given the short observation period, it was not possible to demonstrate any improvement in outcomes.

Fracture-related hip pain in elderly patients with proximal femoral fracture after discharge from stationary treatment

Background: Proximal femoral fracture is a common condition in the elderly but very little is known about fracture‐related hip pain in these patients after discharge from stationary treatment.

On the prognosis of hip fractures. Assessment of mortality after hip fractures by analyzing overlapping segments of longitudinal data

ZusammenfassungHintergrundDie Behandlung der Schenkelhalsfraktur im Akutkrankenhaus wird in Deutschland seit dem Beginn der 90er Jahre im Rahmen einer externen Qualitätssicherungsmaßnahme erfasst. Es liegen jedoch keine Daten über das weitere Schicksal der Patienten vor, sodass die Ergebnisqualität der Behandlung über den Aufenthalt im Akutkrankenhaus hinaus bisher verborgen blieb.Patienten und MethodeIm Rahmen sektorübergreifender Versorgungsforschung wurden Daten von 1393 Patienten des Jahres 1999 im Rahmen einer retrospektiven Untersuchung zusammengeführt. Die Daten entstammen der Projektgeschäftsstelle externe Qualitätssicherung der Ärztekammer Westfalen Lippe, der Allgemeinen Ortskrankenkasse AOK und dem Medizinischen Dienst der Krankenkasse MDK. Die statistische Auswertung erfolgte unter Beachtung des Datenschutzes durch das Koordinierungszentrum für klinische Studien der Universität Düsseldorf.ErgebnissePrognoserelevante Parameter für das Überleben nach einer Schenkelhalsfraktur sind sowohl in univariaten als auch in multivariaten Analysen das Geschlecht, das Alter, das Vorhandensein einer Pflegestufe vor der Fraktur, der Status des Heimbewohners, die Höhe der ASA-Klassifikation und das Vorhandensein postoperativer Komplikationen. Der Operationszeitpunkt spielt für die Überlebensprognose keine Rolle.SchlussfolgerungenNur die gegenseitige Öffnung der getrennten Versorgungssektoren des Gesundheitssystems ermöglicht die Herausarbeitung klarer Prognosefaktoren für die Patienten. Die Untersuchung zeigt, dass die Überlebenswahrscheinlichkeit der Patienten durch die Einleitung einer Rehabilitationsmaßnahme statistisch signifikant gebessert werden kann.AbstractBackgroundData on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care.Material and methodIn a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf.ResultsUni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival.ConclusionsPrognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

Zur Prognose der Schenkelhalsfraktur

ZusammenfassungHintergrundDie Behandlung der Schenkelhalsfraktur im Akutkrankenhaus wird in Deutschland seit dem Beginn der 90er Jahre im Rahmen einer externen Qualitätssicherungsmaßnahme erfasst. Es liegen jedoch keine Daten über das weitere Schicksal der Patienten vor, sodass die Ergebnisqualität der Behandlung über den Aufenthalt im Akutkrankenhaus hinaus bisher verborgen blieb.Patienten und MethodeIm Rahmen sektorübergreifender Versorgungsforschung wurden Daten von 1393 Patienten des Jahres 1999 im Rahmen einer retrospektiven Untersuchung zusammengeführt. Die Daten entstammen der Projektgeschäftsstelle externe Qualitätssicherung der Ärztekammer Westfalen Lippe, der Allgemeinen Ortskrankenkasse AOK und dem Medizinischen Dienst der Krankenkasse MDK. Die statistische Auswertung erfolgte unter Beachtung des Datenschutzes durch das Koordinierungszentrum für klinische Studien der Universität Düsseldorf.ErgebnissePrognoserelevante Parameter für das Überleben nach einer Schenkelhalsfraktur sind sowohl in univariaten als auch in multivariaten Analysen das Geschlecht, das Alter, das Vorhandensein einer Pflegestufe vor der Fraktur, der Status des Heimbewohners, die Höhe der ASA-Klassifikation und das Vorhandensein postoperativer Komplikationen. Der Operationszeitpunkt spielt für die Überlebensprognose keine Rolle.SchlussfolgerungenNur die gegenseitige Öffnung der getrennten Versorgungssektoren des Gesundheitssystems ermöglicht die Herausarbeitung klarer Prognosefaktoren für die Patienten. Die Untersuchung zeigt, dass die Überlebenswahrscheinlichkeit der Patienten durch die Einleitung einer Rehabilitationsmaßnahme statistisch signifikant gebessert werden kann.AbstractBackgroundData on the treatment of hip fractures in acute care settings have been collected in a report card system for quality assurance in Germany since the beginning of the 1990s. However, there are no data on the long-term outcome and long-term quality of care.Material and methodIn a retrospective study, data on 1393 patients from 1999 were collected from different sources: from the department of quality assurance at the medical association of Westfalia-Lippe, the Statutory Health Insurance Funds (AOK), and the Medical Review Board of the Statutory Health Insurance Funds (Medizinischer Dienst der Krankenkasse, MDK). Statistical analyses were performed by the Center for Clinical Studies of the University of Düsseldorf.ResultsUni- and multivariate analyses reveal the following prognostic parameters for survival after hip fracture: sex, age, nursing care dependency, living in a nursing home, risk stratification according to ASA, and postoperative complications. Timing of the operation had no affect on survival.ConclusionsPrognostic factors for the outcome after hip fracture can only be obtained by analyzing data from the hospital stay and the post-hospital setting as well. Chances of survival can be significantly improved by rehabilitative care.

Die Schenkelhalsfraktur des jüngeren Patienten Widerspruch zwischen Leitlinie und Versorgungswirklichkeit – Ergebnisse externer Qualitätssicherung bei 1747 Verläufen

ZusammenfassungZwischen dem 01.01.1993 und dem 31.12.1998 wurden 26.005 Patienten mit der Diagnose einer Schenkelhalsfraktur ausschließlich durch chirurgische oder unfallchirurgische Kliniken oder Abteilungen im Ärztekammerbereich Westfalen-Lippe behandelt und deren Ärztekammer erfasst. 1747 Patienten waren zwischen 10 und 60 ” der Versorgungswirklichkeit im Kammerbereich gegenübergestellt. Ergebnisse. Der Anteil konservativer Behandlungen sank 1998 bis auf 2% ab, nur 43% dieser jüngeren Patieten werden als Notfall erkannt. Nur 45,4% aller Osteosynthesen werden am Aufnahmetag vorgenommen, annähernd 30% dieser Patienten werden schon primär mit einer Endoprothese versorgt. Der Operationszeitpunkt ist abhängig von Operationshäufigkeit und Spezialisierung: je mehr Schenkelhalsoperationen im Jahr in einer Abteilung erfolgen, desto kürzer ist die präoperative Liegezeit; in unfallchirurgisch spezialisierten Abteilungen ist der Anteil an Sofortoperationen höher als in allgemeinchirurgisch ausgerichteten Kliniken, ohne dass durch die frühe Versorgung die Komplikationrate oder die Letalität ansteigen. Fazit. Die Versorgungswirklichkeit entspricht nicht dem Anspruch der Fachgesellschaft, angesichts des Alters der Patienten bedarf es weiterer gemeinsamer Anstrengungen.AbstractBetween January 1993 and December 1998 26.005 patients with hip fractures underwent treatment in departments of general surgery and traumatology in Westfalia-Lippe, Germany. Data of these patients were reported to the chamber of physicians where a report card system for external quality assurance has been established since 1991. 1.747 patients were between 10 and 60 years of age. Treatment according to the guideline of hip fractures of the German College of Traumatology is compared to treatment in reality. Results. Conservative treatment declined to 2% in 1998; only 43% of these comparetively young patients were labeled as emergencies. Only 45.4% of all osteosyntheses were performed on the day of hospital admission. Almost 30% of the patients undergo hip replacement as first line therapy. Timing of operation is related to the frequency of operations per department and specialisation: the more operations per year the shorter the length of stay before operation. Early treatment is more likely in departments of traumatology than in departments of general surgery. Lethality and morbidity do not increase with early treatment. Conclusions. The reality of treatment of hip fractures does not meet the criteria of the guideline. Further efforts have to be undertaken for the benefit of relatively young patients with hip fractures.

Einjahresverläufe nach proximalen Femurfrakturen

BACKGROUND Proximal femur fractures are common and treatment is expensive. The aim of the present study was - after matching of hospital and health insurance data - to evaluate the influence of early operation on certain outcome parameters. Data from a German health insurance were used to identify then influence of the day of operation after admittance on the rate of mortality, decubitus, and revision surgery during the hospital stay and on the care level of the patients up to 1 year and in some cases longer after operation. MATERIALS AND METHODS In all, 7905 patients were included. The descriptive data, specifying the given population, described the hospital stay (occurrence, surgical procedures, early complications, secondary diagnoses, length of stay) and the course of patient recovery up to 1 year after the hospital stay (care level, late complications). The calculated data (analytical statistics) give correlations evaluating the influence of the length of the preoperative hospital stay on the outcome parameters mentioned above. Risk adjustment was performed by using secondary diagnoses. RESULTS The study included more women (mean age 81.5 years). Most common was the femoral neck fracture. Of the operations 77% were carried out on the first day after admission; dominating procedures were intramedullary nails and prostheses. Most common secondary diagnoses were diabetes, dementia, ischemic heart disease, and chronic heart insufficiency. Descriptive data revealed 6% early as well as late complications. In all, 50% of patients had a higher care level after operation. Almost 40% of patients changed from outpatient care to inpatient care. The time interval between admission and operation negatively influenced all outcome parameters. The relative risk to die, to develop decubitus, or to receive early revision was increased by approximately one third when patients were operated on later than the first day after admission. A total of 3172 patients died during the study period. Mortality after operation reached 9.9% within 30 days and 26.9% at 1 year. The mortality of patients operated after the first day was increased by more than 6% compared to patients treated within the first 24 h. CONCLUSION The present study clearly presents the importance of analysis of routine records after discharge and it demonstrates that longer periods up to 1 year and more can be evaluated. The data show that a longer time period between hospital admission and operation negatively influences all outcome parameters. The care data give impressive evidence for a significant loss of quality of life and the importance of intense postoperative rehabilitation.