Indirect effect of the COVID-19 pandemic on hospital mortality in patients with hip fracture: a competing risk survival analysis using linked administrative data

Abstract

BackgroundHip fracture is a leading cause of disability and mortality among older people. During the COVID-19 pandemic, orthopaedic care pathways in the National Health Service in England were restructured to manage pressures on hospital capacity. We examined the indirect consequences of the pandemic for hospital mortality among older patients with hip fracture, admitted from care homes or the community.MethodsRetrospective analysis of linked care home and hospital inpatient data for patients with hip fracture aged 65 years and over admitted to hospitals in England during the first year of the pandemic (1 March 2020 to 28 February 2021) or during the previous year. We performed survival analysis, adjusting for case mix and COVID-19 infection, and considered live discharge as a competing risk. We present cause-specific hazard ratios (HRCS) for the effect of admission year on hospital mortality risk.ResultsDuring the first year of the pandemic, there were 55 648 hip fracture admissions: a 5.2% decrease on the previous year. 9.5% of patients had confirmed or suspected COVID-19. Hospital stays were substantially shorter (p<0.05), and there was a higher daily chance of discharge (HRCS 1.40, 95% CI 1.38 to 1.41). Overall hip fracture inpatient mortality increased (7.2% in 2020/2021 vs 6.4% in 2019/2020), but patients without concomitant COVID-19 infection had lower mortality rates compared with the year before (5.3%). Admission during the pandemic was associated with a 11% increase in the daily risk of hospital death for patients with hip fracture (HRCS 1.11, 95% CI 1.05 to 1.16).ConclusionsAlthough COVID-19 infections led to increases in hospital mortality, overall hospital mortality risk for older patients with hip fracture remained largely stable during the first year of the pandemic.

Effects of the COVID-19 pandemic on secondary care for cardiovascular disease in the UK: an electronic health record analysis across three countries

“… 21 Moreover, prior analyses have tended to be disease- or procedure-specific and have not taken a system-level view across diseases and countries. 22 We now confirm previous reports of reduced activity for admissions and for PCI and other CVD-related procedures, showing variation by timing, speed, and extent of recovery across subtypes. Given the significant backlogs across services in the UK 23–25 and other countries, 26 there is an urgent need to monitor and understand these indirect impacts of the COVID-19 pandemic, to develop coordinated, but tailored responses, based on subtype, type and urgency of care, and country.…”

“…Despite multiple analyses of indirect effects in the UK and other countries using EHR (11)(12)(13)(14)20), these effects have been neglected in pandemic surveillance and policy responses (21). Moreover, prior analyses have tended to be disease-or procedure-specific and have not taken a system-level view across diseases and countries (22). We now confirm previous reports of reduced activity for admissions and for PCI and other CVD-related procedures, showing variation by timing, speed and extent of recovery across subtypes.…”

Hip fracture in the COVID-19 era: what can we say about care and patient outcomes?

“…In this issue of BMJ Quality and Safety , Grimm et al 4 allow us to do both. They analysed national administrative data for England (Hospital Episodes Statistics, HES) for the period of March 2019 to February 2021, comparing mortality and length of stay since the pandemic onset with the year before for three patient groups depending on their usual residence: own home (ie, community based), residential home and nursing home.…”

“…Another facet of redeployment is that one might expect consultant surgeons to perform more hip fracture cases as they are less likely to be performing elective surgery. In this context, it might appear surprising that fewer total hip replacements were performed relative to hemiarthroplasties in the Grimm et al hip fracture cohort4 as, during the pandemic, trained joint replacement surgeons were often redeployed from elective work to trauma care (including the treatment of patients with hip fracture). However, this reflects a broader trend observed since the publication of the hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH) randomised trial, which suggested that total hip replacement for patients with hip fracture was not as superior to alternative treatment options as reported by previous studies 11.…”