A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients

Abstract

Introduction Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study’s aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients. Methods This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum. Results A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0–2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18–30%, p < 0.001], compared to BBt- patients within the same stratum. Conclusion Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

Is nonoperative management of appendicitis inferior in the COVID-19 era?

“…Outcomes for COVID-active and COVID-recovered patients who underwent appendectomy were not significantly different than COVID-negative patients. Our results are echoed by Forssten and colleagues' multicenter cohort study of surgical management of AA, which found no difference in complication rate or LOS between COVID-negative, COVID-active, and COVID-recovered patients 28 . These results may be explained by patient selection because surgeons are likely to recommend NOM for severely symptomatic COVID-19 patients.…”

“…Thus, COVID-active and COVID-recovered patients were most likely asymptomatic or minimally symptomatic, with physiology that was not prohibitive to undergo anesthesia. In fact, Forssten et al 28 reported no difference in American Society for Anesthesiologist physical status class between COVID groups, with the majority being American Society for Anesthesiologist class 1 or 2. In addition, Frankcombe et al 29 reported that 12 asymptomatic COVID-positive patients underwent appendectomy for AA without adverse outcomes.…”

The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures

“…Nevertheless, there remains a significant correlation between dementia and frailty. It should also be emphasized that this study assumes that the OFS and weight loss are markers of frailty, as established by previous research; [ 11 , 14 , 18 , 30 ]; however, it should be acknowledge that these variables indicate the presence of frailty rather than encompassing the concept of frailty itself. Finally, we were only able to establish the association between dementia, frailty and mortality for in-hospital mortality, whereas former studies used up to 1-year mortality [ 7 , 11 , 18 , 30 ].…”

“…It should also be emphasized that this study assumes that the OFS and weight loss are markers of frailty, as established by previous research; [ 11 , 14 , 18 , 30 ]; however, it should be acknowledge that these variables indicate the presence of frailty rather than encompassing the concept of frailty itself. Finally, we were only able to establish the association between dementia, frailty and mortality for in-hospital mortality, whereas former studies used up to 1-year mortality [ 7 , 11 , 18 , 30 ]. Despite the different timepoints for mortality, the results of the current investigation are consistent with previous studies, confirming the robust nature of these results.…”

“…Previous investigations have found an association between preadmission beta-blocker therapy and a reduction in postoperative mortality in hip fracture patients with dementia, a reduction which has also been observed to be larger the more frail a patient was. [ 29 , 30 ]. Nevertheless, future studies will be required to determine if there is any advantage to the initiation of beta-blocker therapy in hip fracture patients.…”