The effect of an in-hospital comprehensive geriatric assessment on short-term mortality during orthogeriatric hip fracture program- which patients benefit the most?

Article The Effect of an In-Hospital Comprehensive Geriatric Assessment on Short-Term Mortality During Orthogeriatric Hip Fracture Program—Which Patients Benefit the Most? Hanna M. Pajulammi, MD 1 , Harri K. Pihlajama ¨ki, MD, PhD 2,3 , Tiina H. Luukkaala, MSc 4,5 , Janne J. Jousma ¨ki, MD 2 , Pekka H. Jokipii, MD 2 , and Maria S. Nuotio, MD, PhD 1 Abstract Aims: To examine the association of patient-related factors with the effect of an in-hospital comprehensive geriatric assessment (CGA) on hip fracture mortality. Methods: Population-based, prospective data were collected on 1425 consecutive hip fracture patients aged 65 in a central hospital providing orthogeriatric service. Outcome was mortality at 1 month after hip fracture associated with receiving versus not receiving CGA. Results: Of the patients receiving CGA compared to those who did not, 8.5% versus12.0% had died within 1 month of the hip fracture (P¼.028). In the ageand sex-adjusted Cox proportional hazards model, CGA was associated with a decreased risk of 1-month mortality in patients aged 80 to 89 years (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.29-0.73), females (HR: 0.57, 95% CI: 0.38-0.86), having American Society of Anesthesiologists (ASA) score 1 to 3 (HR: 0.60, 95% CI: 0.37-0.99), taking 4 to 10 daily medications (HR: 0.59, 95% CI: 0.38-0.91), with a diagnosis of memory disorder (HR: 0.50, 95% CI: 0.29-0.88), with an estimated glomerular filtration rate <30 mL/min/1.73m 2 (HR: 0.28, 95% CI: 0.10-0.76), or living in an assisted living accommodation (HR: 0.40, 95% CI: 0.21-0.76). Conclusion: Several modifiable and patient-related factors were associated with decreased risk of 1-month mortality when CGA was performed during hospitalization for hip fracture. Between “younger and fitter” and “oldest and frailest,” there is a large group of hip fracture patients whose survival can be improved by in-hospital CGA. Keywords hip fracture, orthogeriatric care, comanaged care, comprehensive geriatric assessment, mortality Submitted March 20, 2017. Revised April 24, 2017. Accepted May 27, 2017. Introduction Geriatric hip fractures are an increasing burden as the world population ages. The consequences of hip fractures include high mortality, 1-3 long-term disabilities 1,4 and decreased quality of life, 1 and high costs of care. 3 According to a consensus statement, geriatricians may provide the greatest benefit when caring for the most vulnerable older adults, 5 such as those with hip fracture. To compliment surgical care, various models of multidisciplinary care for patients have been developed. 6 Current literature suggests the use of a comprehensive care approach to decrease mortality in a randomized setting, 7 in a dedicated hip fracture unit 8 and in register-based studies. 9 On the other hand, implementation of 1 Department of Geriatric Medicine, Seina ¨joki Central Hospital, Seina ¨joki, Finland 2 Division of Orthopedics and Traumatology, Seina ¨joki Central Hospital, Seina ¨joki, Finland 3 University of Tampere, Seina ¨joki, Finland 4 Research and Innovation Center, Tampere University Hospital, Tampere, Finland 5 Faculty of Social Sciences, Health Sciences, University of Tampere, Tampere, Finland Corresponding Author: Hanna Pajulammi, Department of Geriatric Medicine, Seina ¨joki Central Hospital, Hanneksenrinne 7, FIN60220, Seina ¨joki, Finland. Email: [email protected] Geriatric Orthopaedic Surgery & Rehabilitation 2017, Vol. 8(4) 183-191 ªThe Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2151458517716516 journals.sagepub.com/home/gos Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). a clinical pathway with a standardized set of orders 10 or including an inpatient geriatric consultation team in the care model 11 demonstrated no effect on mortality. A protocol-driven comanaged comprehensive care system combining a clinical pathway and geriatric care also reduces mortality 12 but not without the involvement of a geriatrician. 13 The implementation and components of orthogeriatric care models vary, 6,10 making it challenging to compare different models. The background components of effective orthogeriatric care are not very well understood or researched. 14 In addition, older hip fracture patients are a heterogeneous group 15,16 and the beneficial actions of care and rehabilitation requirements may vary, which further complicates studies of optimal orthogeriatric models. Moving forward, given the increasing number of hip fractures, limited health-care resources, and the short supply of geriatricians, there is a pressing need to clarify what truly is effective orthogeriatric care. In order to increase equity and effectiveness, targeted and tailored services may be needed. We examined the association of patient-related factors with the effect of an in-hospital comprehensive geriatric assessment (CGA; Table 1) on 1-month mortality among older hip fracture patients in an orthopedic ward during implementation of orthogeriatric hip fracture program (HFP). Methods Study Population This is a retrospectively analyzed study of prospectively collected, population-based data on 1445 consecutive hip fracture Table 1. Summary of Current Components of Seina ¨joki Central Hospital Hip Fracture Program (HFP). Components For All Patients Components of comprehensive geriatric assessment (CGA; when available) Standardized and detailed set of orders on – Examining and imaging – Pain management – Fluid balance and nutritional care with supplements – Type of anesthesia (mainly spinal) – Surgical care for different fracture types – Delirium prevention and management – Oxygen therapy – Erythrocyte transfusion thresholds of hemoglobin – Urinary catheterization practices (removed on 1. postoperative day) – Mobilizing and physiotherapy – Deep venous thrombosis prophylaxis Preround interview by a geriatric hip fracture nurse – Living arrangements and the level of assistance needed before the fracture – Mobility level and walking aids before the fracture – Diagnosis of a memory disease or any concern of cognitive decline (prefracture Mini-Mental Status Examination score, if available) – Detailed information of circumstances of the fall – Mini-Nutritional Assessment, estimated height, weight and body mass index – Calcium intake (dietary and supplements) and vitamin D supplementation – Consent for data collection Discharge Criteria – Stable hemodynamics (oxygen saturation, pulse, and blood pressure, cardiac rhythm) – Hemoglobin > 90 g/L (>100 g/L if severe cardiac condition) – Urinary catheter removed – Pain under control – Patient mobilized – Medications updated to the outpatient file – If treated for infection, declining C-reactive protein (CRP) and fever – 2nd or later postoperative day – No discharge of a patient with immediate poor prognosis Interdisciplinary orthogeriatric ward rounds on weekdays – Staff: geriatrician (or a resident), orthopedic hip fracture nurse, physiotherapist – Encouragement and motivation of the patient – Check-up on the adherence to standardized orders of care protocol – Early detection and treatment of complications – Patient examination: orthostatic blood pressure test, oxygen saturation, orientation, auscultation of cardiac, and pulmonary sounds, any additional examination as needed, evaluation of mobility – Mobilizing the patient – Setting the goal for rehabilitation – Careful evaluation and adjustment of medications – Evaluation of calcium and vitamin D intake and supplements – Orders on examinations needed after discharge (for example, on memory disorder and osteoporosis) Instructions and suggestions to discharge destination – Objectives of treatment and rehabilitation – Physical status at discharge – General instructions on mobilizing (including active walking exercises, encouragement toward independency) – Nutritional plan including supplements – Medications plan and instructions on discontinuation of opiate pain medications – Planned examinations and follow-ups after discharge – Separate discharge documents from all disciplines (geriatrician, orthopedic, nurse, and physiotherapist) 184 Geriatric Orthopaedic Surgery & Rehabilitation 8(4) patients aged 65 years having their first hip fracture between September 2007 and August 2014. The final study population comprised 1425 hip fracture patients as 20 (1.4%)patients declined participation in the study. Pathologic and periprosthetic fractures were excluded. The data were collected at Seina¨joki Central Hospital, Finland, which is the only hospital that provides acute surgical care in the Hospital District of Southern Ostrobothnia, which has a population of 199 000. Hip Fracture Program and Study Design Hip fracture program was first initiated in our hospital in 2007 with the goal of improving the care of hip fracture patients in accordance with evidence-based guidelines. First, a database with demographic, medical, surgical, functional, social, and outcome measures was established. Geriatrician-led interdisciplinary rounds began in 2008. A multidisciplinary orthogeriatric committee was established in 2009 and includes physicians from geriatrics, anesthesia, and orthopedic surgery; nurses from the orthopedic ward; and physiotherapists. Other experts are consulted if needed. The first written HFP with a standardized set of orders for hip fracture patients’ hospital stay was delivered in 2009. The integrated care model is of shared care: Patients are within an orthopedic ward, but the responsibility for the care of the patient is shared between the orthopedic surgeon and the geriatrician. The orthopedic surgeon sees the patient daily and the geriatrician on weekdays, and both services write their own orders. Resident physicians provide some of the care in this model as well. Since its initiation, the HFP has widely expanded and is regularly updated by the orthogeriatric committee, and it has been stabilized from a project to a permanent model of care. The 2013 update of the HFP includes extensive instructions on pre-, peri-, postoperative, and surgical care and CGA, discharge criteria, and recommendations for postdischarge care (Table 1). The emphasis is on detailed, individually adjusted, and multidisciplinary care throughout and after the hospitalization. The physicians and nurses are encouraged to focus on the HFP through continuous education. A dedicated orthogeriatric nurse coordinates the service in the orthopedic ward. The HFP was developed and implemented in a real-life setting with minimal additional resources. There are only a few posts for geriatricians in our hospital, and, like in many regions in Finland, occasional shortage of geriatricians has occurred. As a consequence of this, CGA has not been performed at all times. However, when a geriatrician is available, every hip fracture patient in the orthopedic ward receives CGA without any patient selection by exclusion or inclusion criteria. In the present study, we compared the effect of receiving CGA versus not receiving CGA while hospitalized for hip fracture on 1-month mortality during implementation of the HFP. To identify the specific patient-related factors affecting mortality when combined with CGA, we examined the association of baseline characteristics with the effect of CGA on mortality. By CGA, we mean the components of care as presented in Table 1. Data Collection During hospitalization, the patients’ medical records and interview conducted by a nurse with the patient or a caregiver were used. Data were collected on age, sex, fracture type, American Society of Anesthesiology (ASA) score, on-admission serum creatinine, number of regularly taken medications, regular or as-needed use of hypnotic benzodiazepines and z-hypnotics (BZD-Z; midazolam, temazepam, nitrazepam, triazolam, zaleplon, zolpidem, and zopiclon), prefracture diagnosis of memory disorder, prefracture mobility level and living arrangements, and receiving or not receiving CGA. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used to calculate estimated glomerular filtration rate (eGFR). The results were categorized into 4 groups: 60 mL/ min/1.73 m 2 (normal to mildly decreased eGFR CKD-EPI ), 45 to 59 mL/min/1.73 m 2 (mildlytomoderately decreased eGFR CKD-EPI ), 30 to 44 mL/min/1.73 m 2 (moderately to severely decreased eGFR CKD-EPI ), and under 30 mL/min/ 1.73 m 2 (severely decreased eGFR CKD-EPI or kidney failure). The dates of death were provided by the National Population Register Center and extracted from the electronic patient files of the hospital. There were no losses to mortality follow-up. Statistical Analyses The distribution of patient-related factors in case numbers and percentages according to the CGA were calculated. Differences were tested using Pearson w 2 test or Fisher exact test (Table 2). One-month (1-30 days from hip fracture) mortality was analyzed by ageand sex-adjusted Cox proportional hazards models (Table 3). Ageand sex-adjusted association of receiving versus not receiving CGA with mortality separately in each group of the patient-related factors were performed using the Cox proportional hazards model showing results by hazard ratios with 95%confidence intervals (Table 4). One-month mortality was illustrated by a survival curve (Figure 1). A Pvalue of <.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS for Windows, version 23.0 (IBM Corp, Armonk, New York). Ethical Consideration The study was performed according to the 1964 Helsinki declaration and its later amendments and approved by the Ethics Committee of the Hospital District of South Ostrobothnia. Written informed consent was obtained from the participants or their caregivers. Results Data on 1425 hip fracture patients were available (Tables 2 and 3). The median age was 84 years (interquartile range: 78-88, range: 65-104), and the median length of stay was 6 days (interquartile range: 5-7, range: 1-37). Of the 1425 patients, 886 (62%) received CGA during hospitalization. Of the patients, 36 (3%) patients died during acute hospitalization and Pajulammi et al 185 140 (10%) patients within 1 month. Of the patients receiving CGA, 8.5%died within 1 month of the hip fracture, compared to 12.0%of the patients not receiving CGA (P¼.028). Comprehensive Geriatric Assessment The patients receiving CGA while hospitalized, compared to those who did not, more likely had an ASA score of 1 to 3 (P¼ .002) and lived at home or in an institution (P¼.002). Age, sex, number of regularly taken medications, use of BZD-Zs, diagnosis of memory disease, eGFR CKD-EPI , prefracture mobility level, or fracture type were not significantly different between the 2 groups (Table 2). Ageand Sex-Adjusted 1-Month Mortality In the ageand sex-adjusted Cox regression analysis, patients with older age, higher ASA score, higher number of medications in regular use, having a diagnosis of memory disease, lower eGFR CKD-EPI , living in more supported living Table 2. Distribution of the Patient-Related Factors and Outcome Variables According to Comprehensive Geriatric Assessment. a,b Patient-related factors Total Comprehensive geriatric assessment PValueN¼1425 Yes (n¼886) No (n¼539) Age, n (%) .268 65-79 410 (29) 247 (28) 163 (30) 80-89 759 (53) 469 (53) 290 (54) 90 or over 256 (18) 170 (19) 86 (16) Sex, n (%) .707 Women 1062 (75) 657 (74) 405 (75) Men 363 (26) 229 (26) 134 (25) ASA score, n (%) .002 1-3 1047 (74) 672 (76) 375 (70) 4-5 354 (25) 206 (23) 148 (28) Number of regularly taken medications, n (%) .097 < 4 247 (17) 154 (17) 93 (17) 4-10 916 (64) 554 (63) 362 (67) > 10 261 (18) 177 (20) 84 (16) BZD-Z .153 No 1033 (73) 655 (74) 378 (70) Yes 391 (27) 230 (26) 161 (30) Diagnosis of memory disorder, n (%) .272 No 1038 (73) 635 (72) 403 (75) Yes 379 (27) 247 (28) 132 (25) eGFR CKD-EPI , n (%) .167 > 60 mL/min/1.73m 2 821 (58) 490 (55) 331 (61) 45-59 mL/min/1.73m 2 287 (29) 194 (22) 93 (17) 30-44 mL/min/1.73m 2 193 (14) 125 (14) 68 (13) < 30 mL/min/1.73m 2 87 (6) 55 (6) 32 (6) Mobility level, n (%) .070 Outdoors unassisted 743 (52) 467 (53) 276 (51) Indoors unassisted 557 (41) 354 (40) 223 (41) Assisted only 70 (5) 46 (5) 24 (5) Unable to walk 25 (2) 17 (2) 8 (2) Living arrangements, n (%) .002 Home 565 (40) 362 (41) 203 (38) Home with organized homecare 399 (28) 235 (27) 164 (30) Assisted living accommodation 237 (17) 136 (15) 101 (19) Institutionalized 213 (15) 150 (17) 62 (12) Fracture type, n (%) .545 Neck of femur 886 (62) 541 (61) 345 (64) Intertrochanteric 458 (32) 292 (33) 166 (31) Subtrochanteric 80 (6) 52 (6) 28 (5) Abbreviations: ASA, American Society of Anesthesiologists; BZD-Z, hypnotic benzodiazepines and z-hypnotics (midazolam, temazepam, nitrazepam, triazolam, zaleplon, zolpidem, and zopiclon); eGFR CKD-EPI , estimated glomerular filtration rate calculated by the Chronic Kidney Disease Epidemiology Collaboration equation. a n¼1425. b Missing values are not shown but were tested and included in the percentages. Differences between groups were tested by Pearson w 2 test or Fisher exact test. Statistically significant Pvalues (P< .05) are bolded. 186 Geriatric Orthopaedic Surgery & Rehabilitation 8(4) accommodations, having lower mobility class, and male sex had a greater likelihood of dying within 1 month of the hip fracture (Table 3). The patients receiving CGA were significantly more likely to survive at 1 month after the hip fracture than those not receiving CGA (Table 3). The survival curve is shown in Figure 1. Ageand Sex-Adjusted Analyses of the Effect of CGA With Mortality in the Groups of Patient-Related Factors In the ageand sex-adjusted Cox proportional hazards model, CGA was significantly associated with decreased risk of 1month mortality in patients aged 80 to 89 years, female sex, Table 3. Distribution and Associations of the Patient-Related Factors and Comprehensive Geriatric Assessment According to 1-month Mortality. a Patient-related factors 1-Month Mortality Alive, n¼1285 Deceased, n¼140 Ageand Sex Adjusted n (%) n (%) HR (95% CI) Age 65-79 389 (30) 21 (15) 1.00 80-89 683 (53) 76 (54) 2.21 (1.36-3.59) 90 or over 213 (17) 43 (31) 3.87 (2.28-6.55) Sex Women 970 (76) 92 (66) 1.00 Men 315 (25) 48 (34) 1.80 (1.26-2.45) ASA score 1-3 983 (77) 64 (46) 1.00 4-5 290 (23) 64 (46) 2.75 (1.94-3.91) Number of regularly taken medications < 4 236 (18) 11 (8) 1.00 4-10 832 (65) 84 (60) 1.94 (1.03-3.63) > 10 217 (17) 44 (32) 3.67 (1.89-7.12) BZD-Z No 937 (73) 96 (69) 1.00 Yes 348 (27) 43 (31) 1.09 (0.76 -1.56) Diagnosis of memory disorder No 952 (74) 86 (61) 1.00 Yes 330 (26) 49 (35) 1.55 (1.09-2.20) eGFR CKD-EPI > 60 mL/min/1.73m 2 766 (60) 55 (39) 1.00 45-59 mL/min/1.73m 2 252 (20) 35 (25) 1.69 (1.10-2.59) 30-44 mL/min/1.73m 2 164 (13) 29 (21) 1.93 (1.22-3.07) < 30 mL/min/1.73m 2 69 (5) 18 (13) 2.99 (1.75-5.12) Mobility level Outdoors unassisted 718 (56) 25 (18) 1.00 Indoors unassisted 486 (38) 91 (65) 4.63 (2.95-7.28) Assisted only 58 (5) 12 (9) 4.77 (2.38-9.59) Unable to walk 21 (2) 4 (3) 4.04 (1.40-11.7) Living arrangements Home 543 (42) 22 (16) 1.00 Home with organized homecare 369 (29) 30 (21) 1.79 (1.02-3.14) Assisted living accommodation 197 (15) 40 (29) 3.97 (2.31-6.81) Institutionalized 169 (13) 44 (31) 5.08 (2.98-8.65) Fracture type Neck of femur 800 (62) 86 (61) 1.00 Intertrochanteric 410 (32) 48 (34) 0.99 (0.69 -1.41) Subtrochanteric 74 (6) 6 (4) 0.65 (0.28 -1.49) Comprehensive Geriatric Assessment No 474 (37) 65 (46) 1.00 Yes 811 (63) 75 (54) 0.63 (0.45-0.87) Abbreviations: ASA, American Society of Anesthesiologists, BZD-Z, hypnotic benzodiazepines and z-hypnotics (midazolam, temazepam, nitrazepam, triazolam, zaleplon, zolpidem, and zopiclon), CI, confidence interval; eGFR CKD-EPI , estimated glomerular filtration rate calculated by the Chronic Kidney Disease Epidemiology Collaboration equation; HR, hazard ratio. a n¼1425. b Missing values are not shown but were tested and included in the percentages. Associations with mortality were tested by Cox hazard regression models showing results by HRs and 95% CIs. Pajulammi et al 187 ASA score 1 to 3, using regular or as-needed BZD-Zs, having a diagnosis of memory disease, taking 4 to 10 medications daily, having eGFR CKD-EPI 45 to 59 mL/min/1.73, m 2 or < 30 mL/ min/1.73 m 2 , living in an assisted-living accommodation, or having the fracture in the neck of the femur (Table 4). Discussion Based on our findings, receiving CGA while hospitalized for hip fracture was associated with decreased 1-month mortality. This corroborates with previous literature of HFPs having a protective impact on short-term mortality 7-9,12 Moreover, our study revealed several potentially medically modifiable factors and factors related to prefracture patient characteristics that could explain the protective effect of in-hospital CGA on short-term mortality. In this study, patients aged 80 to 89 years benefitted from the CGA in relation to mortality, whereas younger or older patients did not. Older age is a well-known risk factor for mortality after hip fracture. 2,17 Younger hip fracture patients are less frail 15 and more likely to survive the hip fracture regardless of CGA. Nonagenarians with hip fracture are highrisk patients and are more often anemic and have more adverse events while hospitalized. 17 In our study, CGA was associated with decreased mortality in women but not in men. Although women suffering hip fracture are older, 18 male hip fracture patients have more chronic comorbidities, 18 more severe health conditions, and a higher risk of complications during hospitalization for hip fracture. 19 In addition, male sex itself is a risk factor for mortality in this patient group. 2 It might be that in women, the conditions leading to hip fracture that are more of a concern are general frailty, including many potentially modifiable factors, in which case CGA can be more valuable in relation to mortality. The findings also imply that older men require specific attention regarding hip fracture care. According to the ASA classification, the general health of patients with a score of 1 to 3 varies from healthy to having severe systemic disease. 20 Based on our results, the survival potential of these patients was better when CGA was performed. An important part of the CGA is careful and critical evaluation of the patients’ medications. Our findings revealed that patients taking 4 to 10 regular medications or using BDZ-Z benefitted from CGA in relation to mortality. In a recent study by Gosch et al, only 9.6%of the hip fracture patients were taking appropriate medications. 21 High number of medications 22 and use of BZDs 23 are associated with chronic illnesses, which increase the importance of input from a geriatrician. Renal insufficiency, such as multiple medication use, might be one of the few modifiable risk factors, as the patients with even severe renal insufficiency (eGFR CKD-EPI < 30 mL/min/ 1.73m 2 ) on admission showed improved survival if assessed by a geriatrician. This might be partly due to a synergistic effect with a medication evaluation because the prevalence of potentially inappropriate medications in older patients with chronic kidney disease is high. 24 The protective association of CGA in patients with renal dysfunction may also be explained by more careful fluid therapy. Dehydration is common among hip fracture patients and may increase the risk of acute renal dysfunction with a potentially poor prognosis. 25 During the HFP, CGA was associated with decreased mortality among patients with a prefracture-diagnosed memory disorder. Dementia is a well-known risk factor for mortality among hip fracture patients. 2 Orthogeriatric programs not excluding cognitively impaired patients have been successful in reducing in-hospital 7 and 1-year 8 mortality. In a subgroup analysis of hip fracture patients with dementia, the intervention group experienced fewer complications and better functional recovery, but the multidisciplinary intervention program had no effect on mortality. 26 Poor knowledge of the engagement and recovery capacity of patients with dementia affects their access to rehabilitation after hip fracture, 27 and this may also impact acute care decisions. A geriatric approach includes individual consideration for each patient and no denial of treatment or rehabilitation based merely on a diagnosis of dementia. Furthermore, dementia is an independent risk factor for iatrogenic conditions such as delirium 28 in hip fracture patients. An optimistic attitude combined with professional care, including delirium prevention, 6 may explain some of the results of our study. Patients living in assisted-living accommodations are too frail to survive at home but well enough to avoid institutional living. In our study, this patient group benefitted greatly from CGA with regard to mortality. Community-dwelling hip fracture patients are generally younger and fitter 29 and therefore may have a better prognosis regardless of the geriatrician’s input. Patients living in long-term residential care are generally in worse health and are thus more likely to have a poorer outcome, 30 and the geriatricians’ principal role is to ensure quality of care toward the end of life. In the present study, CGA was associated with improved short-time survival when the patients had a femoral neck Figure 1. One-month survival after hip fracture according to comprehensive geriatric assessment by ageand sex-adjusted Cox proportional hazard model. 188 Geriatric Orthopaedic Surgery & Rehabilitation 8(4) fracture. Patients experiencing other fracture types are older, 17,31 have more comorbidities, 31 and a higher risk of mortality 2,31 which may determine the prognosis beyond the effects of CGA. One of the main strengths of the study is the prospective and population-based design. Also, the data were collected systematically and almost entirely by 1 individual. In addition, cognitive impairment and institutional living were not exclusion criteria, which increases the generalizability of the study. The study also has limitations. Due to the observational and noninterventional nature of this real-life study, there may be some uncertainty in the results. Toward the end of the study time, HFP has become more comprehensive and staff more experienced. Furthermore, there has been secular change toward overall increase in the awareness of the needs of this specific population. Also, although being otherwise similar, the groups receiving versus not receiving CGA differed significantly by the ASA scores and living arrangements. This is due to the fact that the groups were not predetermined or counterbalanced but were formed based on day-to-day availability of a Table 4. Ageand Sex-Adjusted Effect of In-hospital CGA (Total n ¼1425, CGA n ¼886, no CGA n ¼539) on Mortality 1 Month After Hip Fracture in the Groups of Patient-Related Factors. a Mortality Ratio at 1 Month Comparing Groups of CGA versus non-CGA (Total Deaths n¼140) Patient-related factors Total (N) Deaths, n (%) HR 95% CI Age 65-79 410 21 (5.1) 0.74 0.31-1.75 80-89 759 76 (10.0) 0.46 0.29-0.73 90 or over 256 43 (16.8) 0.98 0.52-1.85 Sex Women 1062 92 (8.7) 0.57 0.38-0.86 Men 363 48 (13.2) 0.76 0.42-1.34 ASA 1-3 1047 64 (6.1) 0.60 0.37-0.99 4-5 354 64 (18.1) 0.86 0.53-1.42 Number of regularly taken medications < 4 247 11 (4.5) 0.58 0.17-1.96 4-10 916 84 (9.2) 0.59 0.38-0.91 > 10 261 44 (16.9) 0.58 0.32-1.06 BZD-Z No 1033 97 (9.4) 0.75 0.50-1.13 Yes 391 43 (11.0) 0.38 0.21-0.73 Diagnosis of memory disorder No 1038 86 (8.3) 0.70 0.46-1.07 Yes 379 49 (12.9) 0.50 0.29-0.88 eGFR CKD-EPI > 60 mL/min/1.73m 2 821 55 (6.7) 0.73 0.43-1.24 45-59 mL/min/1.73m 2 287 35 (12.2) 0.46 0.24-0.90 30-44 mL/min/1.73m 2 193 29 (15.0) 0.79 0.36-1.72 < 30 mL/min/1.73m 2 87 18 (20.7) 0.28 0.10-0.76 Mobility level Outdoors unassisted 743 25 (3.4) 0.52 0.24-1.14 Indoors unassisted 557 91 (16.3) 0.75 0.49-1.14 Assisted only 70 12 (17.1) 0.77 0.24-2.42 Unable to walk 25 4 (16.0) 2.32 0.10-53.4 Living arrangements Home 565 22 (3.9) 0.75 0.32-1.75 Home with organized homecare 399 30 (7.5) 0.81 0.39-1.69 Assisted living accommodation 237 40 (16.9) 0.40 0.21-0.76 Institutionalized 213 44 (20.7) 0.73 0.39-1.37 Fracture type Neck of femur 886 86 (9.7) 0.44 0.29-0.68 Intertrochanteric 458 48 (10.5) 1.20 0.65-2.21 Subtrochanteric 80 6 (7.5) 0.50 0.10-2.48 Abbreviations: ASA, American Society of Anesthesiologists, BMI, body mass index; BZD-Z, hypnotic benzodiazepines and z-hypnotics (midazolam, temazepam, nitrazepam, triazolam, zaleplon, zolpidem, and zopiclon), eGFR CKD-EPI, estimated glomerular filtration rate calculated by the Chronic Kidney Disease Epidemiology Collaboration equation. a Statistically significant Pvalues (P< .10) are bolded. Pajulammi et al 189 geriatrician and without preselection of patients. Further studies are warranted to examine whether the findings observed in the present study also apply to other outcomes such as readmissions, mobility and living arrangements, and on mortality in longer term. We believe that a somewhat longer centralized acute postoperative period and rehabilitation in a dedicated orthogeriatric unit with in-hospital CGA is needed to further improve the outcomes. In conclusion, the observation in our study of the protective association of in-hospital CGA in patients with multiple medications and renal insufficiency with hip fracture mortality highlights the significance of comprehensive and proactive medical assessment and interventions as fundamental part of acute orthogeriatric care. The orthogeriatric approach for younger and fitter patients did not have an effect on short-time mortality. Also, in relation to mortality, the oldest and frailest patients with the worst prognosis did not benefit of it either. These patients are, however, at the core of geriatric know-how, 5 and the quality of care for those patients that are toward the end of life should be improved by having a geriatrician in the hip fracture team. After all, HFPs aim not only at reducing mortality but also at improving the quality of care. 10,12 Between the extremes of low-risk and high-risk patients is a large group of patients whose potential to survive might go unnoticed in traditional care. Including a geriatrician and a CGA in the HFP can actually save the lives of these patients. Authors’ Note The data sets supporting the conclusions of this article are not available in an open access repository because the data sets contain information by which the participants may be directly or indirectly identified. Informed consent from participants and the approval by the Ethics Committee of the Hospital District of South Ostrobothnia was obtained for publication of study results, but not for the publication of patient raw-data separately. Further, the data used in this study are a part of a clinical quality register of Seina¨joki Central Hospital and is continuously being updated. If anyone is interested in exploring specific issue, please contact Maria S. Nuotio, MD, PhD. Email: mar- [email protected]. Tel. þ358-6-41533179. Acknowledgments We would like to acknowledge Kaisu Haanpa¨a¨, RN for her expert data collection. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was financially supported by the Competitive Research Fund of the Hospital District of Southern Ostrobothnia; and by the Competitive State Research Financing of Seina¨joki Central Hospital. The institutions of financial support did not participate in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. ORCID iD Hanna M. Pajulammi, MD http://orcid.org/0000-0003-4249-1672 References 1. Griffin XL, Parsons N, Achten J, Fernandez M, Costa ML. Recovery of health-related quality of life in a United Kingdom hip fracture population. the Warwick hip trauma evaluation–a prospective cohort study. Bone Joint J. 2015;97-B(3):372-382. 2. Hu F, Jiang C, Shen J, Tang P, Wang Y. 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