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Revista Pan-Amazônica de Saúde

versão impressa ISSN 2176-6215versão On-line ISSN 2176-6223

Rev Pan-Amaz Saude vol.15  Ananindeua  2024  Epub 08-Fev-2024

http://dx.doi.org/10.5123/s2176-6223202401381 

ORIGINAL ARTICLE

Hip fracture in Pará State, Brazil: officially recorded mortality and comorbidities in the elderly population. Retrospective cohort study

Fratura de quadril no estado do Pará, Brasil: mortalidade oficialmente registrada e comorbidades na população idosa. Estudo de coorte retrospectivo

Ana Beatriz Favacho Silva (orcid: 0000-0001-5414-995X)1  , Maria Clara Pinheiro da Silva (orcid: 0000-0001-7697-7406)2  , Gustavo Kalif Lima (orcid: 0000-0002-9727-6964)1  , George Kalif Lima (orcid: 0000-0002-0702-0501)1  , João Alberto Ramos Maradei-Pereira (orcid: 0000-0003-4330-9406)1  2 

1 Hospital Maradei, Departamento de Ortopedia e Traumatologia, Belém, Pará, Brasil

2 Universidade Federal do Pará, Faculdade de Medicina, Belém, Pará, Brasil

ABSTRACT

OBJECTIVE:

To assess factors related to death among the elderly within one year after hip fracture surgery in Pará State, Brazil, Amazon Region.

MATERIAL AND METHODS:

A retrospective cohort study was performed using data collected from a referral center for orthopedic surgery and death records from the Pará State Health Department. We enrolled patients aged 60 years or older who were hospitalized for fractures in the proximal third of the femur between January 2015 and December 2016 (N = 542). Data were described using absolute and relative frequencies, means, medians, and respective standard deviations, minimum and maximum values. Clinical and sociodemographic factors associated with death up to one year after hip fracture surgery were investigated. We hypothesized that a delay in surgical intervention would correlate with an increased mortality risk.

RESULTS:

The death rate within one year was 12.2%. Together, the days between fracture and surgery did not have a statistically significant impact on one-year mortality (OR = 1.01; 95% CI: 1.00-1.03), nor did respiratory comorbidities (OR = 3.04; 95% CI: 0.92-10.06). Only age (OR = 1.053; 95% CI: 1.023-1.084) and male sex (OR = 2.11; 95% CI: 1.24-3.60) were statistically significant with higher mortality one year after surgery.

CONCLUSION:

Age and male sex were identified as factors associated with one-year mortality. Despite the challenges related to transportation and the limited availability of public health care in the Amazon Region, the delay in surgery did not emerge as a determinant of the mortality outcome.

Keywords: Hip Fractures; Aged; Mortality; Health Services for the Aged; Transportation of Patients

RESUMO

OBJETIVO:

Avaliar fatores relacionados à mortalidade entre idosos um ano após cirurgia de fratura de quadril no estado do Pará, Brasil.

MATERIAIS E MÉTODOS:

Estudo de coorte retrospectivo utilizando dados de um centro de referência em cirurgia ortopédica e registros de óbito da Secretaria de Estado da Saúde do Pará. Foram incluídos pacientes com 60 anos ou mais hospitalizados por fraturas no terço proximal do fêmur entre 2015 e 2016 (N = 542). Os dados foram descritos por frequências absolutas e relativas, médias, medianas, desvios padrão, valores mínimos e máximos. Fatores clínicos e sociodemográficos associados à morte até um ano após a cirurgia de fratura de quadril foram investigados. Hipotetizamos que o atraso na intervenção cirúrgica correlacionaria com um aumento no risco de mortalidade.

RESULTADOS:

A taxa de mortalidade em um ano foi de 12,2%. O intervalo de dias entre a fratura e a cirurgia não teve impacto estatisticamente significativo na mortalidade em um ano (OR = 1,01; IC 95%: 1,00-1,03), assim como as comorbidades respiratórias (OR = 3,04; IC 95%: 0,92-10,06). Apenas a idade (OR = 1,053; IC 95%: 1,023-1,084) e o sexo masculino (OR = 2,11; IC 95%: 1,24-3,60) foram estatisticamente significativos com maior mortalidade um ano após a cirurgia.

CONCLUSÃO:

Idade e sexo masculino foram identificados como fatores associados à mortalidade em um ano. Apesar dos desafios relacionados ao transporte e à limitada disponibilidade de cuidados de saúde públicos na Região Amazônica, o atraso na cirurgia não emergiu como determinante do desfecho de mortalidade.

Palavras-chave: Fraturas de Quadril; Idoso; Mortalidade; Serviços de Saúde para Idosos; Transporte de Pacientes

INTRODUCTION

Physiological changes inherent to aging predispose to fractures and their complications, which are related to unfavorable outcomes like death1. Worldwide, elderly mortality is high one year after hip fractures, with rates ranging from 22.8% to 29.5%2,3. In Brazil, accessing public hospitals poses challenges, and there are also delays in surgery for these cases4. These delays may heighten the risk of death during hospitalization and within one year, particularly in the Brazilian Public Health System (Sistema Único de Saúde - SUS) hospitals5,6. This can be particularly relevant in areas where transportation is difficult, such as the Amazon Region, where many roads are unpaved, ambulances are insufficient, and riverside populations remain isolated due to the lack of quick river transportation for these situations.

Despite the widely available evidence about mortality after hip fracture worldwide, the studies are usually based on areas of high urbanization2,5,6. In contrast, no data on death rates is available specifically in the Amazon Region. Therefore, formulating evidence-based public health policies becomes a challenge.

Nevertheless, hip fractures are frequent in Amazon. According to the national public health system register, only 1,825 hip fractures were notified between January 2015 and December 2016 in Pará State7. Given the gap in the literature, this study aimed to investigate the factors associated with death up to one year after hip fracture surgery among the elderly admitted to an orthopedic referral hospital in Belém, the capital of Pará, northern Brazil. We hypothesize that associated comorbidities and the time interval between fracture and surgery occurrence influence the patients' survival in one year.

MATERIALS AND METHODS

STUDY DESIGN AND SETTING

This is a retrospective cohort study based on data from medical records. Data were collected from all consecutive patients admitted with hip fracture in Maradei Hospital, in the Belém City, Pará State, Brazil. The hospital is a metropolitan and regional referral center for orthopedic and trauma treatment in Pará. It serves SUS and private individuals through insurance policies, functioning as a teaching hospital for medical students from Federal University of Pará (UFPA).

All patients from SUS were referred to the hospital through Pará's health regulatory system. Those from private insurance were admitted directly from the hospital's emergency department.

ETHICS

The Research Ethics Committee of the Institute of Health Sciences at UFPA approved the study on November 27, 2018, under protocol CAAE 91758418.7.0000.0018. Informed consent was waived, as the study was based mainly on data from medical records; besides, anonymity was guaranteed to the patient and family in cases where a telephone call was accomplished.

PARTICIPANTS AND STUDY SIZE

The hospital admitted patients from the capital, Belém, and its metropolitan region, as well as from the northeast and southeast of the state and from Marajó Island (Figure 1), which were referred by the public health system. Across Pará State, patients from the Tapajós region were the only ones not referred to the hospital. All consecutive elderly patients who received surgical treatment for fractures in the proximal third of the femur (neck, intertrochanteric, and subtrochanteric), between January 1, 2015, and December 31, 2016, were included in the study. The initial date is the inception of the electronic medical records system in the hospital. Therefore, this study used a convenience sample of all consecutive patients for whom it was possible to retrieve data. All patients aged 60 years old or older were considered as elderly. Medical records without an exact surgery date and those treated conservatively were excluded from the study.

Photo: Maria Clara Pinheiro da Silva.

Figure 1 - Map of Pará State showing, in light gray, the area of origin of patients admitted to Maradei Hospital 

VARIABLES AND DATA SOURCES

Possible death in the first year after surgery was verified within a death certificates database provided by the Health Department of the State of Pará (Secretaria do Estado de Saúde do Pará - SESPA) for this study. The dates and causes of death were registered. The cause of death was recorded using an International Statistical Classification of Diseases and Related Health Problems Code (ICD10).

Additional information was also gathered from the medical records, including demographics (age at surgery, sex, and origin), general clinical characteristics (comorbidities, smoking status, date of admission, date of hospital discharge, and date of death if occurred), as well as clinical details related to the hip fracture (affected side of fracture and fracture site, type of surgery, date of fracture, and date of surgery).

The following comorbidities were registered: systemic arterial hypertension, diabetes mellitus, history of stroke, other heart diseases, Alzheimer's disease, and prostate cancer. The presence of pulmonary comorbidities was also verified, such as pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), asthma, and hyper and hypothyroidism. Patients who used at least one smoked tobacco product at least once a week were considered current tobacco users. Patients who declared they did not smoke for at least one year were identified as former smokers.

The proportion of patients undergoing surgery within 48 h of the fracture was evaluated by analyzing the trauma and the surgery dates. This timeframe is considered optimal for minimizing postoperative risks of mortality8,9. Clinical and demographic variables associated with surgery delay (operations taking place after the window of 48 h from the trauma) were investigated.

SOURCES OF BIAS

To mitigate the risk of clerical errors in death certificates, we attempted to confirm the cause and date of death by making telephone contact with the families of the deceased. All data collected for this study were recorded by one researcher and independently double-checked by another.

STATISTICAL ANALYSIS

The binary variables in all patients were described using absolute and relative frequencies. Quantitative characteristics used summary measures (mean, standard deviation, median, minimum, and maximum)10. According to each binary variable, mortality within one year was characterized in absolute and relative frequencies, and the association was verified using chi-square tests or exact tests (Fisher test or likelihood ratio test)10. Quantitative variables were described according to one-year mortality and were compared using the Student's t-test or Mann-Whitney test10. In addition, the unadjusted odds ratios (OR) of each variable of interest with one-year mortality, along with the respective 95% confidence intervals, were estimated in bivariate logistic regression11.

A multiple logistic regression model was performed11, with variables that presented a descriptive level of less than 0.20 (P < 0.20) in the bivariate analyses entering the multiple model, keeping all the variables selected in the model, the "full model", to jointly assess the characteristics that influenced one-year mortality. To avoid multicollinearity, the variable "days between fracture and surgery" was selected instead of the variables "days between fracture and hospitalization" and "days between hospitalization and surgery" since the chosen variable encompasses the other two times.

Microsoft Excel 2003 and IBM-SPSS for Windows v20.0 software were used to tabulate and analyze the data. A significance level of 5% was considered.

RESULTS

Over the two-year study period, the hospital admitted 814 elderly patients for hip fracture treatment, encompassing femoral neck, intertrochanteric, and subtrochanteric regions of the hip. Forty-eight patients for whom the fracture date was unavailable were excluded, along with 224 who were treated conservatively. The remaining 542 cases were evaluated for this study.

Most patients were female (64.9%) and 80 years old or older (55.7%), with the mean age as 80 years (standard deviation - SD of 9.5 years; minimum of 60, maximum of 112 years). When admitted to the hospital, 236 patients (43.5%) were under treatment for hypertension, 110 (20.3%) for diabetes, and 30 (5.5%) suffered from other cardiovascular diseases. At the moment of fracture, 81 (14.9%) were smokers (Table 1).

Table 1 - Epidemiological characteristics of all evaluated patients who treated hip fracture at Maradei Hospital, Pará State, Brazil, 2015-2016 

Variables Patients
N %
Age (years old)
60 to 69 88 16.2
70 to 79 152 28.0
80 to 89 227 41.9
≥ 90 75 13.8
Sex
Female 352 64.9
Male 190 35.1
Laterality
Right 253 46.7
Left 289 53.3
Controlled systemic arterial hypertension
No 306 56.5
Yes 236 43.5
Controlled diabetes mellitus
No 432 79.7
Yes 110 20.3
Other cardiovascular disease
No 512 94.5
Yes 30 5.5
Smoker
No 461 85.1
Yes 81 14.9
Stroke history
No 520 95.9
Yes 22 4.1
Alzheimer's disease
No 515 95.0
Yes 27 5.0
Pulmonary comorbidity
No 527 97.2
Yes 15 2.8
Prostate cancer history
No 539 99.4
Yes 3 0.6
Current hyperthyroidism
No 541 99.8
Yes 1 0.2
Current hypothyroidism
No 539 99.4
Yes 3 0.6

The most common type of fracture was intertrochanteric (63.1%). Most patients were treated with cephalomedullary nails (48.0%) or bipolar hip hemiarthroplasty (27.3%). As shown in table 2, most patients lived outside the capital (59.0%), where the hospital is located (59%), and the mean time between the fracture and hospital admission was 8.7 days (SD 10.7), with 12.4 mean days between fracture and surgery (SD 12.3). The time between fracture and surgery was below 48 h for 20 (3.7%) patients.

Table 2 - Orthopedic procedure to treat hip fracture of all evaluated patients at Maradei Hospital, Pará State, Brazil, 2015-2016 

Variables Patients
N %
Fracture site
Femoral neck 172 31.7
Subtrochanteric 28 5.2
Intertrochanteric 342 63.1
Type of surgery
Cephalomedullary nail 260 48.0
Bipolar hip hemiarthroplasty 148 27.3
Total hip arthroplasty 19 3.5
Dynamic hip screw plate 90 16.6
External fixator 2 0.4
Cannulated screws 4 0.7
Dynamic condylar screw plate 18 3.3
Girdlestone 1 0.2
City
Belém (capital) 222 41.0
Countryside 320 59.0
Death in one year
No 476 87.8
Yes 66 12.2
Days between fracture and hospital admission
Mean and standard deviation 8.7 ± 10.7
Median (minimum; maximum) 6 (- ; 108)
Days in hospital
Mean and standard deviation 5.8 ± 3.3
Median (minimum; maximum) 5 (1; 43)
Days between hospital admission and surgery
Mean and standard deviation 3.7 ± 6.4
Median (minimum; maximum) 3 (- ; 127)
Days between fracture and surgery
Mean and standard deviation 12.4 ± 12.3
Median (minimum; maximum) 10 (1; 135)
Time between fracture and surgery > 48 h
No 20 3.7
Yes 522 96.3

Conventional sign used: - Numerical data equal to zero not resulting from rounding.

Death registers were examined among the 542 patients who underwent surgery, and it was identified that 66 (12.2%) of them had died within one year of the procedure. For two patients, the death date was unknown (although certified). The most common causes of death were pulmonary (36.4%) and cardiac or cardiovascular events (18.2%). However, six patients did not have a cause of death described, and the other five were registered as "deaths without assistance". The only case of cancer, specifically uterine cancer, was a pre-existing condition prior to the hip surgery. In the only case where "death due to hip fracture" was registered, the patient had been indicated for a second surgery, but the procedure had been delayed due to difficulties in transportation to the hospital, as described in the medical record (Table 3).

Table 3 - Cause of death in all assessed patients, according to the ICD-10 code, registered in SESPA's database, 2015-2017 

Death cause / ICD-10 code Days between surgery and death
Pulmonary events
I26 - Pulmonary embolism 324
J96.0 - Acute respiratory failure 245
J96.0 - Acute respiratory failure 71
J96.0 - Acute respiratory failure 138
J96.0 - Acute respiratory failure 66
J96.0 - Acute respiratory failure 156
J96.0 - Acute respiratory failure 125
J96.0 - Acute respiratory failure 36
J96.0 - Acute respiratory failure 14
J96.0 - Acute respiratory failure 6
J96.0 - Acute respiratory failure 132
J96.0 - Acute respiratory failure 129
J96.0 - Acute respiratory failure 30
J96.0 - Acute respiratory failure 53
J96.0 - Acute respiratory failure 1
R09.2 - Respiratory arrest 18
R09.2 - Respiratory arrest 23
R09.2 - Respiratory arrest 13
R09.2 - Respiratory arrest 312
R09.2 - Respiratory arrest 73
R09.2 - Respiratory arrest 41
R09.2 - Respiratory arrest 266
R09.2 - Respiratory arrest 187
R09.2 - Respiratory arrest 2
Cardiovascular events
I63.9 - Cerebral infarction, unspecified 72
I63.9 - Cerebral infarction, unspecified 142
I63.9 - Cerebral infarction, unspecified 143
I63.9 - Cerebral infarction, unspecified 175
I60.9 - Nontraumatic subarachnoid hemorrhage, unspecified 4
Cardiac events
I48 - Atrial fibrillation and flutter 14
I21 - Acute myocardial infarction 9
I46 - Cardiac arrest 12
I46 - Cardiac arrest 262
I46 - Cardiac arrest 101
I46.9 - Cardiac arrest, cause unspecified 254
I46.9 - Cardiac arrest, cause unspecified 318
Shock
R57.0 - Cardiogenic shock 141
R57.0 - Cardiogenic shock 76
R57.0 - Cardiogenic shock 23
R57.8 - Other shock 110
R57.8 - Other shock 122
R57.8 - Other shock 357
R57.9 - Shock, unspecified 133
Unspecified septicemia
A41.9 - Sepsis, unspecified organism 286
A41.9 - Sepsis, unspecified organism 258
A41.9 - Sepsis, unspecified organism 85
A41.9 - Sepsis, unspecified organism 64
A41.9 - Sepsis, unspecified organism 134
A41.9 - Sepsis, unspecified organism 343
A41.9 - Sepsis, unspecified organism 55
A41.9 - Sepsis, unspecified organism 7
A41.9 - Sepsis, unspecified organism 159
Uterine cancer
C55 - Malignant neoplasm of uterus, part unspecified 268
Femoral fracture
S72 - Fracture of femur 20
Dementia
F03 - Unspecified dementia 48
Not defined
R99 - Ill-defined and unknown cause of mortality 265
R99 - Ill-defined and unknown cause of mortality 158
R99 - Ill-defined and unknown cause of mortality 117
R99 - Ill-defined and unknown cause of mortality 89
R99 - Ill-defined and unknown cause of mortality 192
R99 - Ill-defined and unknown cause of mortality 4
Death without assistance
R98 - Unattended death 41
R98 - Unattended death 309
R98 - Unattended death 17
R98 - Unattended death 32
R98 - Unattended death 324

In the univariate analysis, the variables identified as related to death in one year were age, sex, days between fracture and hospital admission, days between hospital admission and surgery, and days between fracture and surgery (Table 4). However, in the multivariate logistic regression (Table 5), the days between fracture and surgery (OR = 3.04; P = 0.169) are not significantly related to mortality in one year. Despite being the most common causes of death, respiratory comorbidities (OR = 3.04; P = 0.070) were not related to death in one year after hip surgery either. For every one year added to age, the risk of death increased 5.5%. Men with hip fractures had a 111% higher chance of dying one year after hip surgery than women.

Table 4 - A description of one-year mortality based on each evaluated characteristic and the results of the unadjusted analysis for patients undergoing surgical treatment for hip fractures at Maradei Hospital, Pará State, Brazil, 2015-2016 

Variables Death in one year 95% CI P-value
No Yes Odds ratio Inferior Superior
N = 476 % N = 66 %
Age (interval)
Mean and standard deviation 79.5 ± 9.4 83.7 ± 9.5 1.049 1.019 1.078 0.001*
Age (years old)
60 to 69 81 92.0 7 8.0 1 0.105
70 to 79 138 90.8 14 9.2 1.17 0.46 3.03
80 to 89 196 86.3 31 13.7 1.83 0.77 4.33
≥ 90 61 81.3 14 18.7 2.66 1.01 6.98
Sex
Female 318 90.3 34 9.7 1 0.015
Male 158 83.2 32 16.8 1.89 1.13 3.18
Laterality
Right 225 88.9 28 11.1 1 0.460
Left 251 86.9 38 13.1 1.22 0.72 2.05
Controlled systemic arterial hypertension
No 266 86.9 40 13.1 1 0.468
Yes 210 89.0 26 11.0 0.82 0.49 1.39
Controlled diabetes mellitus
No 381 88.2 51 11.8 1 0.600
Yes 95 86.4 15 13.6 1.18 0.64 2.19
Stroke history
No 456 87.7 64 12.3 1 > 0.999
Yes 20 90.9 2 9.1 0.71 0.16 3.12
Other cardiovascular disease
No 451 88.1 61 11.9 1 0.395
Yes 25 83.3 5 16.7 1.48 0.55 4.01
Alzheimer's disease
No 451 87.6 64 12.4 1 0.761
Yes 25 92.6 2 7.4 0.56 0.13 2.44
Pulmonary comorbidity
No 465 88.2 62 11.8 1 0.097
Yes 11 73.3 4 26.7 2.73 0.84 8.83
Smoker
No 405 87.9 56 12.1 1 0.960
Yes 71 87.7 10 12.3 1.02 0.5 2.09
Fracture site
Femoral neck 151 87.8 21 12.2 1 0.940
Subtrochanteric 24 85.7 4 14.3 1.2 0.38 3.8
Intertrochanteric 301 88.0 41 12.0 0.98 0.56 1.72
Type of surgery
Cephalomedullary nail 225 86.5 35 13.5 1 0.807
Bipolar hip hemiarthroplasty 129 87.2 19 12.8 0.95 0.52 1.72
Total hip arthroplasty 18 94.7 1 5.3 0.36 0.05 2.76
Dynamic hip screw plate 81 90.0 9 10.0 0.71 0.33 1.55
External fixator 2 100.0 - - ND
Cannulated screws 4 100.0 - - ND
Dynamic condylar screw plate 16 88.9 2 11.1 0.80 0.18 3.65
Girdlestone 1 100.0 - - ND
Days between fracture and hospital admission 1.01 0.99 1.03
Mean and standard deviation 8.4 ± 10.5 10.4 ± 12.3 0.008§
Median (minimum; maximum) 5 (- ; 108) 7 (- ; 92)
Days in hospital
Mean and standard deviation 5.7 ± 3.3 6.3 ± 3.3 1.05 0.98 1.11 0.078§
Median (minimum; maximum) 5 (1; 43) 6 (3; 23)
Days between hospital admission and surgery
Mean and standard deviation 3.7 ± 6.7 4 ± 2.7 1.01 0,97 1.04 0.033§
Median (minimum; maximum) 3 (- ; 127) 3.5 (1; 14)
Days between fracture and surgery
Mean and standard deviation 12.1 ± 12.3 14.4 ± 12.6 1.01 1.00 1.03 0.002§
Median (minimum; maximum) 9 (1; 135) 12 (1; 95)
Time between fracture and surgery > 48 h
No 18 90.0 2 10.0 1 > 0.999
Yes 458 87.7 64 12.3 1.26 0.29 5.55
City
Belém (capital) 193 86.9 29 13.1 1 0.599
Countryside 283 88.4 37 11.6 0.87 0.52 1.46

Conventional sign used: - Numerical data equal to zero not resulting from rounding; CI: Confidence interval; p-values from Chi-square test except: * Student t-test; Fisher's exact test; Likelihood ratio test; § Mann-Whitney test; ND: Unable to estimate.

Table 5 - Result of the multiple model to explain mortality in one year according to the evaluated characteristics of the patients undergoing hip fracture surgical treatment at Maradei Hospital, 2015-2016 

Variable OR 95% CI P-value
Inferior Superior
Age (years old) 1.053 1.023 1.084 < 0.001
Sex (male) 2.11 1.24 3.60 0.006
Pulmonary comorbidity 3.04 0.92 10.06 0.07
Days between fracture and surgery 1.01 1.00 1.03 0.161

CI: Confidence interval; OR: Odds ratio.

DISCUSSION

This study identified a mortality rate of 12.2% in one year after hip surgery, with age and sex as the main variables associated with death. While the time between fracture and surgery was associated with mortality in isolated analysis, it lost statistical significance in multivariate analysis, a similar pattern with respiratory comorbidities. This result implies we could not substantiate the hypothesis that a prolonged interval between fracture and surgery impacts mortality. Nevertheless, the study highlights that elderly patients with hip fractures are succumbing to respiratory and cardiovascular diseases. We speculate that adequate primary care could have been prevented some of these deaths. Perhaps preventive measures to control high blood pressure, diabetes, and preventable infectious diseases are still finding barriers to reaching the communities that live alongside the rivers in the Amazon.

The death rate in this study is similar to the 12% rate found in a study in Taiwan, where the intertrochanteric fracture was more prevalent12. However, other studies have even higher rates, of 19% or 26%13,14.

The epidemiological profile of the patients analyzed here is not different from other national studies, which also show, for example, that the female sex is the most prevalent in hip fractures15,16. When analyzing one-year mortality, male gender is the most prevalent, consistent with findings in other studies6,17,18. Age affected the death rate: for each year added to age, there was a 5.5% higher chance of mortality in this study, a similar number to what was found in another evaluation in the South of Brazil, which registered an 8% increase per year in the risk19.

The hospital where this study was conducted is a referral center for hip surgery for the public system. It receives patients from SUS across the state that are not equipped or staffed to treat them surgically. Nearly 60% of our patients were non-residents in the capital, Belém, and required transportation by river and roads to reach the hospital for treatment. These trips took, on average, 8.4 days (from fracture to hospitalization). Inter-city transportation for hip surgery is common in Brazil20. Only 20 patients in this study underwent surgery within 48 h of the trauma. Cases not treated within this time window may entail a worse prognosis and higher healthcare costs associated with sequelae20,21; although, in fact, it has not affected the death rate in other studies22,23. We could not find any significant difference between these 20 and the remaining patients who had to wait more time.

Some authors argue that a delay exceeding 48 h may permit the stabilization of comorbidities that could otherwise impact surgical outcomes22. However, one must consider that the conditions of the hospitals where patients wait for surgery can be far from ideal, especially in the Amazon Region. The delay in surgery can affect prognosis and is associated with a higher risk of nosocomial pneumonia and reoperations due to other infections24,25. The higher hospital infection risk, especially among the elderly, speaks in favor of trying to operate in 48 h8,9.

Hip fractures mainly affect the elderly. Moreover, this population tends to present chronic comorbidities. It is natural that the death rates one year after hip fracture surgical treatment be related to diseases such as anemia, dementia, myocardial infarction, and chronic obstructive pulmonary disease5,22. The elderly with hip fractures tend to suffer from hypertension and diabetes, too16. However, no specific association between these chronic diseases and mortality after one year was found in this study sample.

The most frequently recorded causes of death among the patients within one year were pulmonary and cardiovascular events. The confidence in these data, sourced from death rate certificates within the Pará State system, might be appropriately questioned. However, the limitations in information quality and the absence of specific details on pulmonary diseases or cardiac events causing death hinder more in-depth analyses26,27,28.

Another limitation of the present study is the small sample. It is known that there is underreporting of deaths in Pará State because families in riverside communities fail to notify the death of relatives due to social and economic restraints. It is estimated that 7% of deaths in Pará are not notified29,30, and although we tried to mitigate this by making telephone calls to the families, we could not identify further deaths. Also, there is the possibility that some patients have died even before receiving adequate treatment, and so were not included in this research. Notwithstanding, the sample highly represents what happens in the Pará region and allows future comparisons.

CONCLUSION

Considering the local realities, ensuring that patients have access to surgical treatment for hip surgery 48 h after the trauma can be challenging. Although a significant association between this delay and mortality was not found, we conclude that reducing this time is justified by preventing complications that can impact patients' lives and healthcare systems. More extensive and in-depth investigations into the causes of death among patients operated for hip fractures are necessary to facilitate better planning of healthcare and logistics, particularly in the context of transporting patients in the Amazon.

ACKNOWLEDGEMENTS

The authors thank the Secretaria de Saúde do Estado do Pará and all health professionals who kindly offered their time helping to collect data for this research.

REFERENCES

1 Bilik O, Damar HT, Karayurt O. Fall behaviors and risk factors among elderly patients with hip fractures. Acta Paul Enferm. 2017 Jul-Aug;30(4):420-27. Doi: 10.1590/1982-0194201700062 [Link] [ Links ]

2 Pollmann CT, Røtterud JH, Gjertsen JE, Dahl FA, Lenvik O, Årøen A. Fast track hip fracture care and mortality - an observational study of 2230 patients. BMC Musculoskelet Disord. 2019 May;20(1):248. Doi: 10.1186/s12891-019-2637-6 [Link] [ Links ]

3 Lin JCF, Liang WM. Mortality, readmission, and reoperation after hip fracture in nonagenarians. BMC Musculoskelet Disord. 2017 Apr;18(1):144. Doi: 10.1186/s12891-017-1493-5 [Link] [ Links ]

4 Edelmuth SVCL, Sorio GN, Sprovieri FAA, Gali JC, Peron SF. Comorbidities, clinical intercurrences, and factors associated with mortality in elderly patients admitted for a hip fracture. Rev Bras Ortop. 2018 Sep-Oct;53(5):543-51. Doi: 10.1016/j.rboe.2018.07.014 [Link] [ Links ]

5 Guerra MTE, Viana RD, Feil L, Feron ET, Maboni J, Vargas ASG. One-year mortality of elderly patients with hip fracture surgically treated at a hospital in Southern Brazil. Rev Bras Ortop. 2017 Jan-Feb;52(1):17-23. Doi: 10.1016/j.rboe.2016.11.006 [Link] [ Links ]

6 Correa JGL, Andrade-Silva FB, Fortes Filho S, Kojima KE, Silva JS, Leme LEG. Evaluation of predictive factors of in hospital mortality in patients with proximal femoral fracture. Acta Ortop Bras. 2020 Jan-Feb;28(1):40-3. Doi: 10.1590/1413-785220202801215801 [Link] [ Links ]

7 Ministério da Saúde (BR). Departamento de Informática do Sistema Único de Saúde. Morbidade hospitalar do SUS - por local de internação - Pará [Internet]. Brasília: DATASUS; 2016 [citado 2021 nov 11]. Disponível em: Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/nipa.def . [ Links ]

8 American College of Surgeons. Best practices in the management of orthopaedic trauma [Internet]. Chicago: ACS, Committee on Trauma; 2015 [cited 2021 Nov 15]. Available from: Available from: https://doh.wa.gov/sites/default/files/legacy/Documents/2900//MgmtOrthopaedicTrauma.pdf . [ Links ]

9 Lisk R, Yeong K. Reducing mortality from hip fractures: a systematic quality improvement programme. BMJ Qual Improv Rep. 2014 Sep;3(1):u205006.w2103. Doi: 10.1136/bmjquality.u205006.w2103 [Link] [ Links ]

10 Kirkwood BR, Sterne JAC. Essential medical statistics. 2nd ed. Malden (Mass): Blackwell Science, 2003. 502 p. [ Links ]

11 Hosmer DW, Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000. 320 p. [ Links ]

12 Lin WP, Wen CJ, Jiang CC, Hou SM, Chen CY, Lin J. Risk factors for hip fracture sites and mortality in older adults. J Trauma Acute Care Surg. 2011 Jul;71(1):191-7. Doi: 10.1097/TA.0b013e31821f4a34 [Link] [ Links ]

13 Daraphongsataporn N, Saloa S, Sriruanthong K, Philawuth N, Waiwattana K, Chonyuen P, et al. One-year mortality rate after fragility hip fractures and associated risk in Nan, Thailand. Osteoporos Sarcopenia. 2020 Jun;6(2):65-70. Doi: 10.1016/j.afos.2020.05.005 [Link] [ Links ]

14 Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register. BMC Musculoskelet Disord. 2018 Oct;19(1):369. Doi: 10.1186/s12891-018-2276-3 [Link] [ Links ]

15 Farias FID, Terra NL, Guerra MTE. Evaluation of the effectiveness of a care program for elderly patients with hip fractures: a network strategy. Rev Bras Geriatr Gerontol. 2017 Sep-Oct;20(5):702-12. Doi.org/10.1590/1981-22562017020.170008 [Link] [ Links ]

16 Silva ERR, Marinho DF. Perfil epidemiológico de idosos com fratura proximal de fêmur atendidos no Hospital Regional do Baixo Amazonas, Santarém, PA, Brasil. Rev Kairos-Gerontologia. 2018;21(3):217-37. Doi: 10.23925/2176-901X.2018v21i3p217-236 [Link] [ Links ]

17 Guzon-Illescas O, Perez Fernandez E, Crespí Villarias N, Donate FJQ, Peña M, Alonso-Blas C, et al. Mortality after osteoporotic hip fracture: incidence, trends, and associated factors. J Orthop Surg Res. 2019 Jul;14(1):203. Doi: 10.1186/s13018-019-1226-6 [Link] [ Links ]

18 Chow SKH, Qin JH, Wong RMY, Yuen WF, Ngai WK, Tang N, et al. One-year mortality in displaced intracapsular hip fractures and associated risk: a report of Chinese-based fragility fracture registry. J Orthop Surg Res. 2018 Sep;13(1):235. Doi: 10.1186/s13018-018-0936-5 [Link] [ Links ]

19 Ribeiro TA, Premaor MO, Larangeira JA, Brito LG, Luft M, Guterres LW, et al. Predictors of hip fracture mortality at a general hospital in South Brazil: an unacceptable surgical delay. Clinics. 2014 Apr;69(4):253-8. Doi: 10.6061/clinics/2014(04)06 [Link] [ Links ]

20 Bortolon PC, Andrade CLT, Andrade CAF. O perfil das internações do SUS para fratura osteoporótica de fêmur em idosos no Brasil: uma descrição do triênio 2006-2008. Cad Saude Publica. 2011 abr;27(4):733-42. Doi: 10.1590/S0102-311X2011000400012 [Link] [ Links ]

21 Chiou BL, Chen YF, Chen HY, Chen CY, Yeh SCJ, Shi HY. Effect of referral systems on costs and outcomes after hip fracture surgery in Taiwan. Int J Qual Health Care. 2020 Dec;32(10):649-57. Doi: 10.1093/intqhc/mzaa115 [Link] [ Links ]

22 Espinosa KA, Gélvez AG, Torres LP, García MF, Peña OR. Pre-operative factors associated with increased mortality in elderly patients with a hip fracture: A cohort study in a developing country. Injury. 2018 Jun;49(6):1162-8. Doi: 10.1016/j.injury.2018.04.007 [Link] [ Links ]

23 Franco LG, Kindermann AL, Tramujas L, Kock KS. Fatores associados à mortalidade em idosos hospitalizados por fraturas de fêmur. Rev Bras Ortop. 2016 set-out;51(5):509-14. Doi: 10.1016/j.rboe.2016.08.006 [Link] [ Links ]

24 Öztürk B, Johnsen SP, Röck ND, Pedersen L, Pedersen AB. Impact of comorbidity on the association between surgery delay and mortality in hip fracture patients: a Danish nationwide cohort study. Injury. 2019 Feb;50(2):424-31. Doi: 10.1016/j.injury.2018.12.032 [Link] [ Links ]

25 Glassou EN, Kjørholt KKE, Hansen TB, Pedersen AB. Delay in surgery, risk of hospital-treated infections and the prognostic impact of comorbidity in hip fracture patients. A Danish nationwide cohort study, 2005-2016. Clin Epidemiol. 2019 May;11:383-95. Doi: 10.2147/CLEP.S200454 [Link] [ Links ]

26 Passos VMA, Champs APS, Teixeira R, Lima-Costa MFF, Kirkwood R, Veras R, et al. The burden of disease among Brazilian older adults and the challenge for health policies: results of the Global Burden of Disease Study 2017. Popul Health Metr. 2020 Sep;18(Suppl 1):14. Doi: 10.1186/s12963-020-00206-3 [Link] [ Links ]

27 GBD 2016 Brazil Collaborators. Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study 2016. Lancet. 2018 Sep;392(10149):760-75. Doi: 10.1016/S0140-6736(18)31221-2 [Link] [ Links ]

28 Paula FL, Cunha GM, Leite IC, Pinheiro RS, Valente JG. Elderly readmission and death after discharge from treatment of hip fracture, occurred in public hospitals from 2008 to 2010, Rio de Janeiro. Rev Bras Epidemiol. 2015 Apr-Jun;18(2):439-53. Doi: 10.1590/1980-5497201500020012 [Link] [ Links ]

29 Oliveira ATR, organizador. Sistemas de estatísticas vitais no Brasil: avanços, perspectivas e desafios [Internet]. Rio de Janeiro: IBGE; 2018 [citado 2021 nov 11]. Disponível em: Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101575.pdf . [ Links ]

30 Pourabbas B, Emami MJ, Vosoughi AR, Mahdaviazad H, Kargarshouroki Z. Mortality and function after surgically-treated hip fracture in adults younger than age 60. Acta Ortop Bras. 2017 Jul-Aug;25(4):129-31. Doi: 10.1590/1413-785220172504158145 [Link] [ Links ]

How to cite this article / Como citar este artigo: Silva ABF, Silva MCP, Lima GK, Lima GK, Maradei-Pereira JAR. Hip fracture in Pará State, Brazil: officially recorded mortality and comorbidities in the elderly population. Retrospective cohort study. Rev Pan Amaz Saude. 2024;15:e202401381. Doi: https://doi.org/10.5123/S2176-6223202401381

Received: September 22, 2022; Accepted: November 10, 2023

Correspondence / Correspondência: João Alberto Ramos Maradei-Pereira. Hospital Maradei. Av. Nazaré, 1203. Bairro: Nazaré. Zip code: 66040-145 - Belém, Pará, Brazil - Phone #: +55 (91) 98461-2753. E-mail: jamaradei@ufpa.br

CONFLICTS OF INTEREST

The authors declare there are no conflicts of interest involved in this research.

AUTHORS' CONTRIBUTION

Each author contributed individually and significantly to the development of this article. Silva ABF: conceptualization, data curation, formal analysis, investigation, methodology, and manuscript writing. Silva MCP: data curation, formal analysis, visualization, manuscript writing, reviewing, and editing. Lima Gustavo K: conceptualization, investigation, and methodology. Lima George K: conceptualization, investigation, and methodology. Maradei-Pereira JAR: conceptualization, formal analysis, methodology, project administration, supervision, manuscript writing, reviewing, and editing. All authors revised the final version submitted to the journal and agreed to be accountable for all aspects of the work.

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