PhD student: Baptiste Boukebous

Title: Epidemiology of hip fractures in patients aged over 60 in France: description and search for medical and organisational prognostic factors based on the Nationwide Sample of Statutory-Health-Insurance Beneficiaries.

Supervisor(s): Pr. David Biau (Université Paris Cité), Pr Fei Gao (EHESP)

Doctoral school : ED 393 : Ecole Doctorale Pierre Louis de Santé Publique

Thesis abstract:

Hip fractures (IF) are on the increase, and mainly occur in a context of ageing and frailty. The 2017 French’s High Authority of Health (HAH) recommendation preconized multidisciplinary management, surgery within 24 to 48 hours, and early rehabilitation. There are limited studies allowing a national evaluation of IF in France.

This work focuses on IF surgically treated on over the period 2005-2017, using data from the Nationwide Sample of Statutory-Health-Insurance Beneficiaries. It is divided into six chapters and objectives. The first was an overall description of the FESFs, on a national scale: care pathways, types of care facilities, and changes in mortality and incidence over the recruitment period. The second produced a new prognostic score, called ABCDEFG, which is simple and in line with the overall geriatric assessment. The third focused on mechanical complications. The fourth identified prognostic organisational parameters, using the Annual Statistics of Healthcare Facilities databases. The fifth focused on patients on long-term anticoagulant therapy. The sixth chapter was a cohort study from the North Parisian Hospitals group, comparing the COVID period in 2020 with a control period in 2019.

There was a considerable territorial heterogeneity in terms of home/hospital distance and operating time. Activity was gradually transferred to the public sector. Only the operating time was a powerful prognostic factor (HR=1.35 CI95% [1.15 ;1.5], p=0.0001), half of the fractures were operated >24h, and about 25% >48h. The ABCDEFG items were age, any cerebral or psychiatric pathology, organ failure, undernutrition criteria, social problem, associated trauma, and male sex. Each additional point reduced 90-day survival by approximately 5%. There was no overall reduction in mechanical complications over time, and we found no significant difference between the types of arthroplasties. Geriatric mobile teams, particularly those intervening in emergency departments, were a robust protective factor, including for patients without comorbidity, but their effect was greatest for a surgical delay of less than 1-2 days (HR=0.81, CI95%[0.68;0.98], p=0.03). An unbalanced ratio of junior/senior surgeons in orthopaedic departments was also a risk factor for mortality. Long-term anticoagulation increased the risk of minor complications during hospitalisation. After propensity scoring, the mortality for patients on long-term anticoagulants was similar to that for patients without anticoagulation, up to 7-9 months postoperatively, and then dropped significantly after that. Finally, during the initial stage of the COVID pandemic, we observed a significant excess mortality not attributable to COVID, but very probably to the shutdown of the usual orthogeriatric pathway. This was a very “strict” orthogeriatric model, with immediate medical care and a daily combined visit.

In conclusion, the results suggest that the current HAH recommendation should be strengthened and refocused on the <24h period, and that the definition of the “fast track emergency unit” should include both surgical and medical immediate management, including for patients without comorbidities. Follow-up of frail patients should also be extended beyond 3 months.

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