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PAPERS: Michael J Goldacre, Stephen E Roberts, and David Yeates Mortality after admission to hospital with fractured neck of femur: database study BMJ 2002; 325: 868-869 [Full text]

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It is neither co-morbidity, frailty nor advanced age

Richard G Fiddian-Green   (18 October 2002)

What about asian population?

Sameer Badarudeen   (9 November 2002)

Mortality rates after hip fracture in persons aged 65 years and over

Norbert Specht-Leible, Peter Oster   (27 November 2002)

It is neither co-morbidity, frailty nor advanced age 18 October 2002
Richard G Fiddian-Green, None None Send response to journal: Re: It is neither co-morbidity, frailty nor advanced age	This illuminating study shows that fractured hips are far more likely to be lethal than commonly supposed. The variation in operative mortality observed between Oxfordshire trusts is unlikely to be the product of limited resources or staff shortages for there may even be a wider variation in London teaching hospitals which have the same economic and labour constraints. In addressing the deficiencies in care the first action might be to introduce continuous outcome auditing to get a better grasp of all the relevant variables including the training, experience and competence of the surgeons and to facilitate the evolution of better outcomes (1). The second action might be to include longer term postoperative risk when obtaining informed consent for anaesthesia and surgery (2). The third action to consider in optimising both short and long-term outcome might be achieving complete resuscitation, which may require much earlier stabilisation of the fracture, as soon after sustaining a fracture as is possible and avoiding blood transfusions (3,4). The fourth action to consider might be attempting to reduce short and long-term morbidity and mortality by colonic lavage. Colonic lavage might have a dramatic effect upon outcome by reducing the possibility of translocation of bacterial endotoxin from the colon in patients who develop haemodynamically uncompensated or haemodynamically compensated shock (4,5). Seemingly by releasing cytokines which uncouple oxidative phosphorylation bacterial endotoxin causes a marked impairment of oxygen uptake and utilisation in animal studies thus compounding the severity of any inadequacy of mitochondrial oxidative phosphorylation induced by hypovolaemia, cardiac failure or hypoxaemia.An impairment of oxygenuptake and utilisation is arguably the most lethal of all causes of impaired tissue oxygenation. “The persistently increased standardised mortality ratio”, it was concluded in the present study, “ may indicate continuing sequelae of the fracture or that people fracturing their neck of femur are more frail and ill than the general population of similar age”. All the data gathered prospectively from major elective surgery suggest that this may indeed be the case and that co-morbidity, including “frailty” and advanced age, may be insignificant relative to those variables considered above contrary to what is commonly supposed. 1 Fiddian-Green RG "Auditing" in routine surgical practice bmj.com/cgi/eletters/324/7351/1448#23021, 14 Jun 2002 2. Fiddian-Green RG. The need to include postoperative risk bmj.com/cgi/eletters/325/7363/548#25292, 7 Sep 2002 3. Fiddian-Green RG Failures of surgical care and outcome from cancer surgery bmj.com/cgi/eletters/320/7239/895#7229, 31 Mar 2000 4. Fiddian-Green RG. Mitochondrial considerations bmj.com/cgi/eletters/325/7367/735/a#26019, 4 Oct 2002 5. Fiddian-Green RG Colonic lavage for severe haemorrhagic shock? bmj.com/cgi/eletters/325/7366/674/b#25839, 27 Sep 2002 6. Fiddian-Green RG. Gastric lavage for major operations? bmj.com/cgi/eletters/325/7366/674/b#25849, 27 Sep 2002
What about asian population? 9 November 2002
Sameer Badarudeen, Post-graduate student in Orthopaedics Medical College Trivandrum, Kerala , India Send response to journal: Re: What about asian population?	I am currently doing a study to find out the mortality rate especially one year mortality rate following hip fractures in our indian population. I wonder whether this high mortality rate seen among western population comparable to mortality rate in secondaries in bone is found in asian population also. Is there any statistics available on it? Also is it the age related and poor health status of the individual which leads to a fracture and finally result in mortality, rather than fracture directly contributing to it? Dr Sameer Medical College Trivandrum India Competing interests:   None declared
Mortality rates after hip fracture in persons aged 65 years and over 27 November 2002
Norbert Specht-Leible, Senior Consultant Geriatric Medicine Bethanien-Krankenhaus, Rohrbacher Str. 149, 69126 Heidelberg, Germany, Peter Oster Send response to journal: Re: Mortality rates after hip fracture in persons aged 65 years and over	Mortality rates after hip fracture in persons aged 65 years and over Editor – In their paper concerning excess mortality following fractured neck of femur, Goldacre et al. reported that the fracture is often not reported on death certificates even when death occurs soon after fracture.1 That may be due to legalistic policies. In Germany, certifying death caused by fractured hip results in police investigations of the circumstances of the fall. However, doctors here might be persuaded to certify the death as independent of the fracture in order to prevent the family from any additional suffering, resulting in an underestimation of case fatality rates from official death statistics alone. Thus, substantial international differences may occur due to different national legal policies. In addition, the authors raise the question whether mortality rates after hip fracture indicate sequelae of the fracture or the individual´s pre- fracture frailty. Only the former might be reduced by interventions improving case management. We studied functional outcomes in patients aged 65 and over with hip fracture in Heidelberg, Germany. A total of 331 patients (81% female; mean age 81.5 years) presenting at three surgical departments within 12 months were included. There were no significant differences in case management; 82% of the survivors were transferred to the Geriatric Centre for in-hospital rehabilitation. We had substantial inter-hospital differences concerning patients` pre-fracture health (e. g. number of nursing home residents 5%, 23%, and 30%; ADL-dependent patients 18%, 31%, and 36%), and, accordingly, mortality at 6 months (13.3%, 14.0%, and 26.0%). The hospital treating the highest number of patients with pre- fracture poor health had the highest mortality rates. Data suggest that pre-fracture frailty affected patient selection and primary placement, so that frailty rather than in-hospital care correlates with inter-hospital differences in mortality rates. Thus, the emergency physician, the paramedic, the GP or the chief of the local health service authority, by determining appropriate location, determines inter-hospital differences in hip fracture mortality rates. 1 Goldacre MJ, Roberts SE, Yeates D. Mortality after admission to hospital with fractured neck of femur: a database study. BMJ 2002; 325: 868-9. Competing interests:   None declared