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Nonoperative hip fracture management practices and patient survival compared to surgical care: an analysis of Estonian population-wide data

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Abstract

Summary

A notable proportion of hip fracture patients receive nonoperative management, but such practice is seldom analysed. Although highly variable reasons underpin hip fracture nonoperative management, none of these practices conclusively outweigh the superiority of operative management. Nonoperative management should be only considered when surgery is not an option.

Purpose

Reasons underpinning hip fracture (HF) nonoperative management (NOM) are seldom analysed. This study aims to identify the reasons behind NOM and assess the accuracy of these decisions using these patients’ survival compared with those treated with operative management (OM).

Methods

This is a retrospective cohort study based on population-wide administrative health data, including patients aged ≥ 50 with an index HF diagnosis between January 2009 and September 2017. NOM patients were subgrouped according to their expected prognoses, and their survival up to 36 months was compared with those treated surgically.

Results

From a total of 11,210 included patients, 6.8% (766) received NOM. Varying reasons lead to NOM, dividing them further into five distinct subgroups: (I) 46% NOM decision due to poor expected prognosis with OM; (II) 29% NOM decision due to poor expected prognosis for mixed reasons; (III) 15% NOM decision due to good expected prognosis with NOM; (IV) 8.0% NOM decision due to patient’s refusal of OM; and (V) 1.3% NOM decision due to occult HF. Only poor prognosis and patients who refused OM (I, II, IV) had worse survival than OM patients. However, a relatively high proportion of the poor prognosis patients survived 1 year (29%).

Conclusion

Although there was high variability in reasons underpinning HF NOM, none of these practices conclusively outweigh OM’s superiority. NOM should be considered with utmost care and only for patients for whom OM is out of the question — well-defined medical unfitness or carefully considered refusal by understanding the increased mortality risk.

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Data Availability

Data sharing is prohibited by the Estonian Health Insurance Fund due to the possibility of patient identification.

Code availability

The code used for analyses is available from the corresponding author on request.

Abbreviations

CCI:

Charlson comorbidity index score

EHIF:

Estonian Health Insurance Fund

HF:

Hip fracture

NCSP:

Nordic Medico-Statistical Committee’s classification of surgical procedures

NOM:

Nonoperative management

OM:

Operative management

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Acknowledgements

We acknowledge Dr Pirja Sarap and Dr Egon Puuorg for their help in data validation.

Funding

This work was funded by the following projects: Interreg Baltic Sea Region Programme 2014–2020 (#R001) and the Estonian Research Council projects (TARBS14046I and PSG610).

Author information

Author notes

  1. Pärt Prommik and Kaspar Tootsi are authors of equal contribution.

  2. Aare Märtson and Helgi Kolk are authors of equal contribution.

Authors and Affiliations

  1. Department of Traumatology and Orthopaedics, University of Tartu, Tartu, Estonia

    Pärt Prommik, Kaspar Tootsi, Aare Märtson & Helgi Kolk

  2. Traumatology and Orthopaedics Clinic, Tartu University Hospital, Tartu, Estonia

    Pärt Prommik, Kaspar Tootsi, Toomas Saluse, Aare Märtson & Helgi Kolk

  3. Institute of Sport Sciences and Physiotherapy, University of Tartu, Tartu, Estonia

    Pärt Prommik

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Contributions

Contributions of the authors were as follows: PP, KT, AM and HK designed the study; HK and TS validated the data; and PP and KT performed data analysis and wrote the first draft; and all five jointly revised the manuscript to its final form.

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Correspondence to Pärt Prommik.

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Ethics approval

The study was approved by the research ethics committee of the University of Tartu on 17 June 2013 (reference 227/T-12) and the Estonian Data Protection Inspectorate for the use of personalised data on 1 December 2017 (reference 2.2.-1/17/47).

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Prommik, P., Tootsi, K., Saluse, T. et al. Nonoperative hip fracture management practices and patient survival compared to surgical care: an analysis of Estonian population-wide data. Arch Osteoporos 16, 101 (2021). https://doi.org/10.1007/s11657-021-00973-y

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