The present study is a prospective cohort study. It was done at a level-I trauma center in Austria running a Geriatric Fracture Center focused on fragility fracture patients. The Geriatric Fracture Center is characterized by an orthogeriatric co-management model .
No institutional review and approval was necessary in light of the clinical origin of the data, its retrospective analysis, and use of de-identified patient data.
We included all in-hospital fragility fracture patients aged over 70 admitted from a long-term care residence from May 2009 to November 2011. The mean observation was 789 days, with a range from 1 to 1842 days. A total of 265 patients were analyzed, with a mean age of 86.8 ± 6.7 years. The majority of the cohort was female (80 %). We split the study group into two subgroups based on fracture sites (hip fractures and non-hip fractures). Non-hip fractures included humerus, wrist, rip, clavicle and sternum, vertebral, pelvis, including sacrum, lower extremities, including distal femur, and periprosthetic fractures around the knee and tibia. All patient characteristics are shown in Table 1.
Data collection was performed prospectively by a study nurse and four of the authors (MG, YH, TR, and CK) within the scope of a quality management project supported by the district government. The follow-up evaluations at 3, 6, and 12 months were done by a study nurse and two of the authors (TR and CK). Follow-up ended in May 2014. Hospital readmissions due to subsequent fractures were obtained from the hospital information data base, and mortality was crosschecked with the death registry from the governmental institute of epidemiology.
For the basic data set, we collected age, gender, fracture site, and initial treatment (surgical or non-operative) of each patient.
To evaluate and analyze comorbidities, we applied the Charlson Comorbidity Index (CCI) . The CCI is valuable tool to predict the 1-year mortality for patients with up to 22 co-morbid conditions. Each condition is assigned with a score of 1, 2, 3, or 6 depending on the risk of death associated with each condition. The score is summed and given a total score which predicts mortality. The CCI was determined at admission by a geriatrician for all patients. Additional comorbidities, including acute coronary syndrome, atrial fibrillation, heart valve disease, osteoporosis, alcohol abuse, nicotine abuse, depression, pneumonia, pressure ulcers, and sarcopenia, were classified as present or not during the admission.
To assess the pre-fracture functional status, we used a systematized geriatric screening (SGS) described by Lachs . It is a short, simple approach that can be used by physicians to routinely screen the functional status of older people. The screening is on carefully selected tests of vision, hearing, arm, and leg function, urinary incontinence, mental status, instrumental and basic activities of daily living, environmental hazards, and social support systems. It contains 15 items and can be summed-up. This tool is incorporated into the routine clinical practice of our Geriatric Fracture Center at admission.
Mobility was assessed using the Parker Mobility Score . This score evaluates the patient’s ability to walk inside, outside, and when shopping or visiting family. For each question, there are four ordinal responses with a fixed count which are summed. It ranges from 0 to 9 with the maximum scores identifying independent mobility. We assessed the pre-fracture Parker Mobility Score. Functional status was assessed using the Barthel Index (BI)  at day 5 after admission or surgery. Delirium was assessed using the confusion assessment method on all patients during their admission .
Patients underwent a follow-up at 3, 6, and 12 months. Mortality and additional fractures were also assessed during the entire observation time. For follow-up, we assessed the functional status using the BI . The BI is used to measure performance in the basic activities of daily living by scaling the presence or absence of fecal or urinary incontinence, the help needed with grooming, toilet use, feeding, transfers (e.g., from bed to chair), walking, dressing, climbing stairs, and bathing. The maximum score of 100 points indicates that the patient is independent in his basic activities of daily living, and is found to be valid outcome parameter for hip fracture patients .
Follow-up was conducted with the following timeline:
At 3 months: PMS, BI; at 6 months: PMS, BI;
At 12 months: PMS, BI, mortality, and additional readmissions for new fractures;
12 months to end of study: mortality, and additional fracture admissions.
SPSS version 20.0 (2011) was used for the statistical analysis. Metric scaled data are reported as arithmetic mean ± standard deviation and categorical data as absolute frequency and percentage distribution. Non-parametric statistics (Mann–Whitney U-test) were used, since normality assumptions were not met for most of the outcome variables. Group effect and main condition effects were tested for significance by the Mann–Whitney U-test. The Chi-square test for independence was used to determine a possible relationship between two categorical variables. The significance level was defined by p < 0.05. Multivariate logistic regression analysis was performed to identify factors associated with one-year mortality and subsequent fractures. Bivariate analyses were based on logistic regression to generate odds’ ratios (OR) and 95 % confidence intervals (CI). The dependent variable for these analyses was one-year mortality and subsequent fractures. The independent variables were gender, age, BMI, fracture site, surgery vs. conservative treatment, pre-fracture functional status (SGS and PMS), the CCI, and CAM Score.