Mortality Trends in Geriatric Proximal Femoral Fracture Treatments After National Payor Policy Changes: A National Study

Abstract

Introduction: Proximal femoral fractures (PFFs) are a major medical event in an elderly's life. The extent of conservative treatment is poorly evaluated in Western health systems. This study retrospectively examines a national cohort of patients older than 65 years with PFFs treated by early surgery (ES) (<48h), delayed surgery (DS) (>48h), and conservative treatment (COT) over the past decade (2010 to 2019). Results: The study cohort included 38,841 patients; 18.4% were 65 to 74 years, 41.1% were 75 to 84 years, and 40.5% were older than 85 years; 68.5% were female. ES rose from 68.4% in 2013 to 85% in 2017 (P < 0.0001). COT dropped from 8.2% in 2010 to 5.2% in 2019 (P < 0.0001). Level I trauma centers chose 2.3 times less COT (7.75% in 2010 decreased to 3.37% in 2019) while regional hospitals chose COT only 1.4 times less over the years (P < 0.001). Hospitalization periods differed: 6.3 ± 0.6d for COT, 8.6 ± 0.3d for ES, and 12 ± 0.4d for DS (P < 0.001), and the in-hospital mortality rates were 10.5%, 2%, and 3.6%, respectively (P < 0.0001). One-year mortality rates decreased for ES only (P < 0.001). Discussion: ES rose from 58.1% in 2010 to 84.9% in 2019 (P = 0.00002). COT is diminishing throughout the Israeli health system, from 8.2% in 2010 to 5.2% in 2019. Tertiary hospitals consistently practice less COT than regional hospitals (P < 0.001), probably related to surgeons' and anesthetists' appraisal of the patient's medical status and demand. COT had the shortest hospitalization period but carried the highest in-hospital mortality rates (10.5%). The mild difference in out-of-hospital mortality between the COT and DS groups suggests similar patient characteristics that require additional investigation. In conclusion, more PFFs are treated within 48h with a reduced mortality rate, and the 1-year mortality has improved for ES only. Treatment preferences vary between tertiary and regional hospitals.