Surgery for hip fractures is associated with high mortality and morbidity. The causes of poor outcome are not fully understood and may be related to other factors than the surgery itself. The relative contributions of patient, surgical, anaesthetic and structural factors have seldom been studied together. This study, a retrospective registry-based cohort study of 14 932 patients undergoing hip fracture surgery in Sweden from 1st of January 2014 to 31st of December 2016, aimed to identify important predictors of mortality post-surgery. The independent predictive power of our included variables was examined using Cox proportional hazards modeling with all-cause mortality at longest follow-up as the outcome. Twelve independent variables were considered as interrelated exposures and their individual adjusted effect within a single model were evaluated. Kaplan-Meier curves were also generated. Crude mortality rates were 8.2% at 30 days (95% CI 7.7-8.6%) and 23.6% at 365 days (95% CI 22.9-24.2%). Of the 12 factors entered into the Cox regression analysis, age (aHR1.06, p amp;lt; 0.001), male gender (aHR 1.45, p amp;lt; 0.001), ASA-PS-class (ASA 1amp;2 reference; ASA 3 aHR 2.12; ASA 4 aHR 4.79; ASA 5 aHR 12.57 respectively, p amp;lt; 0.001) and PACU-LOS (aHR 1.01, p amp;lt; 0.001) were significantly associated with mortality at longest follow-up (up to 3 years). University hospital status was protective (aHR 0.83, p amp;lt; 0.001) in the same model. Age, gender and 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 modifiable risk factors after multivariable adjustment and require confirmation in future studies.

Background: Preoperative anaemia and red blood cell (RBC) transfusions are associated with poorer clinical outcomes. It is unknown whether perioperative RBC transfusions mediate the relationship between preoperative haemoglobin levels and postoperative outcomes. Methods: This was a prospective observational study among patients aged >= 50 yr undergoing elective major noncardiac surgery from four Swedish hospitals. The co-primary outcomes were 1-yr major adverse cardiovascular and cerebrovascular events (MACCEs) and all-cause mortality. The secondary outcome was a composite of 30-day mortality, MACCEs, acute kidney injury (AKI), pulmonary embolism, anastomotic leak, and postoperative infection. Mediation analyses were conducted with preoperative haemoglobin as the exposure and RBC transfusion as a mediator. Results: Among 1060 patients (mean age 70 [SD 9] yr; 472 [45%] women), 171 patients (16.1%) developed 1-yr MACCEs, and 105 patients (9.9%) died within 1 yr. Preoperative haemoglobin levels were significantly associated with both 1-yr MACCEs (b=-0.015, P=0.041) and all-cause mortality (b=-0.028, P<0.001). Volume of RBC transfusion was not directly associated with the outcomes and did not mediate the relationship between preoperative haemoglobin levels and 1-yr MACCEs (b=-0.001, P=0.451) or all-cause mortality (b=-0.002, P=0.293). For the secondary outcome, RBC transfusions had a significant mediating effect between preoperative haemoglobin and the composite 30-day outcome; however, no direct association was observed (b=0.006, P=0.554). Conclusions:<bold> </bold>Preoperative haemoglobin levels were significantly associated with 1-yr MACCEs and all-cause mortality. This effect was not mediated by perioperative RBC transfusions. Further research is needed to confirm these findings.

Background

The relationship between socioeconomic status and outcomes after hip fracture surgery remains unclear. We aimed to assess the association between individual-level socioeconomic status indicators and mortality after acute hip fracture surgery in Sweden.

Methods

Cross-linked registry-based cohort study of patients undergoing acute hip fracture surgery in Sweden 2015–20. Co-primary outcomes were 30-day and 2-yr all-cause mortality. Socioeconomic status was defined using four indicators: level of education, income, residential area, and receipt of social services. Attributable fractions were calculated to illustrate the potential population-level distribution of mortality differences across SES categories.

Results

There were 58 641 patients included (median age 83 [interquartile range 75–89] yr, 66.1% women). Crude 30-day and 2-yr mortalities were 7.9% (95% confidence interval [CI] 7.7–8.1) and 35.3% (95% CI 34.9–35.7). Level of education showed the strongest association, with a stepwise gradient most pronounced for 2-yr mortality: adjusted odds ratio 1.16 (95% CI 1.08–1.24) for 10–12 yr, 1.20 (95% CI 1.09–1.32) for 9 yr, and 1.25 (95% CI 1.16–1.34) for <9 yr vs >12 yr (all P<0.001). The attributal fraction for 2-yr mortality was 14.0% (standard error 0.022), with an increase in absolute risk of 6.3% (95% CI 4.3–8.2) for >12 yr vs <9 yr of education. Other socioeconomic status factors, except residential area, were also associated with mortality, although less substantially.

Conclusions

Individual socioeconomic status was associated with short- and long-term death after acute hip fracture surgery in Sweden, with education showing the strongest relationship. These findings support consideration of individual-level socioeconomic factors in perioperative hip fracture care at the population level.