Risk factors for hospital re-presentation among older adults following fragility fractures: a systematic review and meta-analysis

Abstract

BackgroundOlder adults hospitalized with fragility fractures are at high risk of negative events that can culminate in re-presentations to hospital emergency departments or readmissions to hospital. This systematic review aimed to identify patient, clinical, or hospital-related factors that are identifiable at the index admission and that may be associated with re-presentations to hospital emergency departments or hospital readmissions in older adults following fragility fractures.MethodsFour electronic databases (PubMed, CINAHL, Embase, and Scopus) were searched. A suite of search terms identified peer-reviewed English-language articles that examined potential correlates of hospital re-presentation in older adults (mean age ≥ 65 years) who were discharged from hospital following treatment for fragility fractures. A three-stage screening process (titles, abstracts, full text) was conducted by two researchers independently. Participant characteristics, study design, potential correlates examined, analyses, and findings were extracted for studies included in the review. Quality and risk of bias were assessed with the Effective Public Health Practice Project Quality Assessment Tool. The strength of evidence was incorporated into a best evidence synthesis, and meta-analysis was conducted where effect pooling was possible.ResultsEleven of 35 eligible studies were categorized as high quality studies. These studies reported that age, higher Cumulative Illness Rating scores, American Society of Anesthesiologists scores > 3, longer length of stay, male sex, cardiovascular disease, low post-operative hemoglobin, kidney disease, dementia and cancer were factors identified at the index admission that were predictive of subsequent re-presentation to hospital. Age was the only predictor for which pooling of effects across studies was possible: pooling was conducted for re-presentation ≤ 30 days (pooled OR, 1.27; 95 % CI, 1.14–1.43) and > 30 days (pooled OR, 1.23; 95 % CI, 1.01–1.50).ConclusionsThe best-evidence synthesis, in addition to the meta-analysis, identified a range of factors that may have utility in guiding clinical practice and policy guidelines for targeted interventions to reduce the need for re-presentation to hospital among this frail clinical population. The paucity of studies investigating re-presentations to hospital emergency departments without admission was an important gap in the literature identified in this review. Key limitations were exclusion of non-English language studies and grey literature.Systematic review registrationPROSPERO CRD42015019379.

The relationship between preoperative American Society of Anesthesiologists Physical Status Classification scores and functional recovery following hip-fracture surgery

“…Our results demonstrated higher preoperative ASA scores correlated with higher hospital readmissions at 6- and 12-months following hospital discharge, which is consistent with previous reports showing higher preoperative ASA scores are associated with more hospital readmissions [ 9 , 10 ] and poorer ambulatory recovery [ 10 , 24 ]. Our findings showed participants with ASA scores of 3 had significantly poorer recovery of walking ability at 1-and 3-months after discharge.…”

“…Similarly, 1-year mortality following surgery for hip fracture was almost 9-times higher for patients with an ASA class of 3 or 4 (severe systemic illness) than patients with an ASA class 1 or 2 [ 8 ]. In addition, higher ASA grades were associated with poorer 30-day outcomes, which included higher mortality, number of comorbidities, and number of inpatient readmissions [ 9 , 10 ]. Higher ASA scores have also been associated with greater pain, less distance walked and poorer movement [ 11 ].…”

Iatrogenic risk factors associated with hospital readmission of elderly patients: A matched case-control study using a clinical data warehouse

“…Many readmission risk factors appeared to be already known in the literature, but few were related to the medications prescribed at discharge of the index hospitalization. Age and sex are known to be readmission risk factors . Thus, controls were matched to cases (1:1), based on their sex and index age (within 5 years), to control for these two risk factors, to have similar populations between cases and controls and to keep patient characteristics, admission characteristics and therapeutic characteristics in the multivariate analysis.…”

External validation of the Rapid Assessment Prioritisation and Referral Tool for multidisciplinary teams in medical assessment and planning units

“…A range of instruments have been used in EDs to detect risk of undesirable health outcomes or events, particularly among the elderly . However, to the authors’ knowledge, the Rapid Assessment Prioritisation and Referral Tool (RAPaRT) is the only instrument specifically developed to assist in the identification of patients with high levels of social or clinical complexity of any adult age that are likely to require a prompt referral to allied members of the multidisciplinary team in short‐stay emergency care settings .…”

“…[8][9][10][11] A range of instruments have been used in EDs to detect risk of undesirable health outcomes or events, particularly among the elderly. [11][12][13][14] However, to the authors' knowledge, the Rapid Assessment Prioritisation and Referral Tool (RAPaRT) is the only instrument specifically developed to assist in the identification of patients with high levels of social or clinical complexity of any adult age that are likely to require a prompt referral to allied members of the multidisciplinary team in short-stay emergency care settings. 11 During the development phase for the RAPaRT, a range of items from existing risk identification tools as well as new items recommended by a multidisciplinary Delphi panel were tested, and the most promising seven items were retained as mandatory items in the RAPaRT.…”