0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Reviews |

Meta-analysis: Excess Mortality After Hip Fracture Among Older Women and Men

Patrick Haentjens, MD, PhD; Jay Magaziner, PhD; Cathleen S. Colón-Emeric, MD; Dirk Vanderschueren, MD, PhD; Koen Milisen, RN, PhD; Brigitte Velkeniers, MD, PhD; and Steven Boonen, MD, PhD
[+] Article and Author Information

From the Universitair Ziekenhuis Brussel, Jette, Vrije Universiteit Brussel, Elsene, and Katholieke Universiteit Leuven and Belgian Centre for Evidence Based Medicine, Leuven, Belgium; University of Maryland, Baltimore, Maryland; and Duke University Medical Center and the Durham Veterans Affairs Medical Center, Durham, North Carolina.


Acknowledgment: The authors thank Dr. Geert Verbeke, head of the Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Katholieke Universiteit Leuven and Universiteit Hasselt for his support during the final revision process of our manuscript.

Grant Support: By the Fund for Scientific Research (G.0488.08); Leuven University; National Institutes of Health (R01 AG06322, R01 HD0073, R37 AG09901, and P60 AG12583); the Paul B. Beeson Award (K23 AG024787); and the Willy Gepts Foundation, Universitair Ziekenhuis Brussel.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-0450.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Haentjens (e-mail, patrick.haentjens@uzbrussel.be).

Requests for Single Reprints: Patrick Haentjens, MD, PhD, Centre for Outcomes Research and Laboratory for Experimental Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium; e-mail, patrick.haentjens@uzbrussel.be.

Current Author Addresses: Dr. Haentjens: Center for Outcomes Research, Laboratory for Experimental Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium.

Dr. Magaziner: Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Suite 200 Howard Hall, 660 West Redwood Street, Baltimore, MD 21201.

Dr. Colón-Emeric: Durham Veterans Affairs Geriatric Research Education and Clinical Center, 508 Fulton Street, Geriatric Research Education and Clinical Center 182, Durham, NC 27705.

Dr. Vanderschueren: Department of Andrology and Endocrinology, Universitair Ziekenhuis Leuven, Campus Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.

Dr. Milisen: Centre for Health Services and Nursing Research, Universitair Ziekenhuis Leuven, Campus Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.

Dr. Velkeniers: Departments of Endocrinology and General Internal Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium.

Dr. Boonen: Leuven University Division of Geriatric Medicine, Universitair Ziekenhuis Leuven, Campus Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.

Author Contributions: Conception and design: P. Haentjens, S. Boonen.

Analysis of the data: P. Haentjens.

Interpretation of the data: P. Haentjens, S. Boonen, J. Magaziner, C.S. Colón-Emeric.

Drafting of the article: P. Haentjens, B. Velkeniers, S. Boonen.

Critical revision of the article for important intellectual content: P. Haentjens, J. Magaziner, C.S. Colón-Emeric, D. Vanderschueren, K. Milisen, B. Velkeniers, S. Boonen.

Final approval of the article: P. Haentjens, J. Magaziner, C.S. Colón-Emeric, D. Vanderschueren, K. Milisen, B. Velkeniers, S. Boonen.


Ann Intern Med. 2010;152(6):380-390. doi:10.7326/0003-4819-152-6-201003160-00008
Text Size: A A A

Background: Although an increased risk for death after hip fracture is well established, whether this excess mortality persists over time is unclear.

Purpose: To determine the magnitude and duration of excess mortality after hip fracture in older men and women.

Data Sources: Electronic search of MEDLINE and EMBASE for English and non-English articles from 1957 to May 2009 and manual search of article references.

Study Selection: Prospective cohort studies were selected by 2 independent reviewers. The studies had to assess mortality in women (22 cohorts) or men (17 cohorts) aged 50 years or older with hip fracture, carry out a life-table analysis, and display the survival curves of the hip fracture group and age- and sex-matched control groups.

Data Extraction: Survival curve data and items relevant to study validity and generalizability were independently extracted by 2 reviewers.

Data Synthesis: Time-to-event meta-analyses showed that the relative hazard for all-cause mortality in the first 3 months after hip fracture was 5.75 (95% CI, 4.94 to 6.67) in women and 7.95 (CI, 6.13 to 10.30) in men. Relative hazards decreased substantially over time but did not return to rates seen in age- and sex-matched control groups. Through use of life-table methods, investigators estimated that white women having a hip fracture at age 80 years have excess annual mortality compared with white women of the same age without a fracture of 8%, 11%, 18%, and 22% at 1, 2, 5, and 10 years after injury, respectively. Men with a hip fracture at age 80 years have excess annual mortality of 18%, 22%, 26%, and 20% at 1, 2, 5, and 10 years after injury, respectively.

Limitations: Cohort studies varied, sometimes markedly, in size, duration of observation, selection of control populations, ascertainment of death, and adjustment for comorbid conditions. Only published data that displayed findings with survival curves were examined. Publication bias was possible.

Conclusion: Older adults have a 5- to 8-fold increased risk for all-cause mortality during the first 3 months after hip fracture. Excess annual mortality persists over time for both women and men, but at any given age, excess annual mortality after hip fracture is higher in men than in women.

Primary Funding Source: Fund for Scientific Research and Willy Gepts Foundation, Universitair Ziekenhuis Brussel.

Figures

Grahic Jump Location
Appendix Figure 1.
Literature search and selection.

Adapted from MOOSE Statement flow diagram (33).

* These 24 articles present survival curves for 22 and 17 unique cohorts of women and men with hip fracture, respectively, as well as age- and sex-matched control groups.

Grahic Jump Location
Grahic Jump Location
Figure 1.
Forest plots of long-term (10-year) all-cause mortality in older women and men.

Squares represent the long-term (10-year) cumulative relative hazard for all-cause mortality according to sex. Horizontal lines indicate 95% CIs. The dotted vertical line is the pooled relative hazard; the solid vertical line is the null effect. The size of the squares is proportional to the weight of the studies.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Forest plots of short-term (1-year) all-cause mortality in older women and men.

Squares represent the short-term (1-year) cumulative relative hazard for all-cause mortality according to sex. Horizontal lines indicate 95% CIs. The dotted vertical line is the pooled relative hazard; the solid vertical line is the null effect. The size of the squares is proportional to the weight of the studies.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 2.
Meta-regression analyses exploring heterogeneity of the cumulative RHs for short-term (1-year) all-cause mortality in older women and men, according to maximum duration of study.

The square represents the Dubbo Osteoporosis Epidemiology Study, which was done in Australia and had a 15-year observation period (66). The authors acknowledge that there was probably selection bias in their study because participants were healthier than nonparticipants (67). RH = relative hazard.

Grahic Jump Location
Grahic Jump Location
Appendix Figure 3.
Meta-regression analyses exploring heterogeneity of the cumulative RHs for short-term (1-year) all-cause mortality in older women and men, according to average probability of death after 1 year.

The square represents the Dubbo Osteoporosis Epidemiology Study, which was done in Australia and had a 15-year observation period (66). The authors acknowledge that there was probably selection bias in their study because participants were healthier than nonparticipants (67). RH = relative hazard.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Relative hazard of all-cause mortality for women and men with hip fracture versus control groups during a given follow-up period starting at the time of injury.

Solid circles represent the pooled relative hazard. Vertical bars represent the corresponding 95% CIs. The dotted horizontal line is the null effect.

Grahic Jump Location
Grahic Jump Location
Figure 4.
Differences in absolute risk for death (excess mortality) from all causes for women and men with hip fracture compared with control participants during a given follow-up period starting at the time of injury.
Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)