scholarly journals Admission Rothman Index, Aspirin, and Intermediate Dose Anticoagulation Effects on Outcomes in COVID-19: A Multi-Site Propensity Matched Analysis

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 23-24
Author(s):  
George Goshua ◽  
Yiwen Liu ◽  
Matthew L. Meizlish ◽  
Rebecca Fine ◽  
Kejal Amin ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Clinical Trials ◽  
Research Funding ◽  
Hospitalized Patients ◽  
Competing Risk ◽  
Hospital Death ◽  
Prophylactic Dose ◽  
Anti Platelet Therapy ◽  
Multivariable Regression ◽  
Intermediate Dose

Introduction: Venous thromboembolism and in-situ small vessel thrombosis are increased in hospitalized patients with COVID-19 in several patient cohorts. Endotheliopathy and activation of both platelets and coagulation predict critical illness and death. For these reasons the use of anti-platelet agents and increased-intensity anticoagulation in the care of hospitalized patients with COVID-19 is under intense study in several clinical trials. We sought to examine the impact of aspirin and anticoagulation on hospitalization outcomes. Methods: We examined outcomes in a large multi-site cohort of consecutive, hospitalized, COVID-19 laboratory confirmed patients under a risk-stratified treatment algorithm from March 13 through June 18, with a focus on efficacy of aspirin and/or increased-intensity anticoagulation. Out of 4150 identified hospitalized patients with COVID-19, we created 3 study cohorts. The overall cohort (2785 patients) excluded pediatric patients, those with incomplete electronic data, and those with multiple admissions. The aspirin (1956 patients) and anticoagulation (1623 patients) cohorts were nested within the overall cohort; the former excluded patients on any home anti-platelet therapy or those who received non-aspirin anti-platelet therapy in the hospital, while the latter excluded patients who did not receive prophylactic or intermediate dose anticoagulation in the hospital. The primary outcome was in-hospital death. Secondary outcomes were time-to-death with a competing risk (time-to-hospital-discharge), escalation to ICU, length-of-stay and use of mechanical ventilation. Variables examined included age, gender, BMI, race, Rothman Index (RI), D-dimer (DD) and patient co-morbidities including cardiovascular disease, chronic kidney disease, and prior VTE. The aspirin and anticoagulation cohorts underwent propensity score (PS) matching utilizing variables found to be significant in multivariable regression modeling in the overall cohort with 638 and 386 patients, respectively. Results: Univariate followed by multivariable regression modeling in the 2785 patient overall cohort established a novel role for RI, and independent roles for age, BMI, and maximum DD, in predicting severity of illness. In all cohorts the 50th and lower percentile of admission RI was predictive of mortality in multivariable modeling (i.e. aspirin: 3rd and 4th admission RI quartiles with HR = 0.18 for both, p<0.001 for both). In PS matched patients, aspirin was associated with a significant decrease in mortality (OR 0.65 [0.42, 0.98], p=0.044) and a significant increase in mechanical ventilation (OR 1.49 [1.03, 2.18], p=0.037) and ICU status (OR = 1.45 [1.06, 1.98], p=0.021). In PS matched patients in the anticoagulation cohort, intermediate versus prophylactic dose anticoagulation was associated with a marginal decrease in mortality (OR 0.60, p=0.053). In the aspirin cohort examining in-hospital death and discharge as competing risks, the use of aspirin was associated with decreased mortality (p=0.042) and had no effect on discharge (p=0.31). In the anticoagulation cohort a similar competing risk model showed the use of intermediate rather than prophylactic anticoagulation decreased mortality (p=0.046) and had no effect on discharge (p = 0.21). Conclusion: We show in a large cohort of consecutively hospitalized patients with COVID-19 treated under a risk-stratified algorithm the prognostic utility of the admission RI in assessing outcomes in hospitalized patients with COVID-19 and a potential benefit of aspirin therapy on in-hospital death from COVID-19. A potential albeit marginal benefit of intermediate dose anticoagulation over prophylactic dose anticoagulation merits further study with results of clinical trials awaited. Figure Disclosures Neuberg: Pharmacyclics: Research Funding; Madrigak Pharmaceuticals: Current equity holder in publicly-traded company; Celgene: Research Funding.

scholarly journals Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: a propensity score-matched analysis

2021 ◽  
Author(s):  
Matthew L. Meizlish ◽  
George Goshua ◽  
Yiwen Liu ◽  
Rebecca Fine ◽  
Kejal Amin ◽  
...  
Keyword(s):  
Propensity Score ◽  
Hospital Mortality ◽  
Antiplatelet Therapy ◽  
Conflict Of Interest ◽  
Cumulative Incidence ◽  
Hospital Death ◽  
Prophylactic Dose ◽  
Multivariable Regression Model ◽  
Multivariable Regression ◽  
Intermediate Dose

ABSTRACTBackgroundThrombotic complications occur at high rates in hospitalized patients with COVID-19, yet the impact of intensive antithrombotic therapy on mortality is uncertain.Research QuestionHow does in-hospital mortality compare with intermediate-versus prophylactic-dose anticoagulation, and separately with in-hospital aspirin versus no antiplatelet therapy, in treatment of COVID-19?Study Design and MethodsUsing data from 2785 hospitalized adult COVID-19 patients, we established two separate, nested cohorts of patients (1) who received intermediate- or prophylactic-dose anticoagulation (“anticoagulation cohort”, N = 1624), or (2) who were not on home antiplatelet therapy and received either in-hospital aspirin or no antiplatelet therapy (“aspirin cohort”, N = 1956). Propensity score matching utilizing various markers of illness severity and other patient-specific covariates yielded treatment groups with well-balanced covariates in each cohort. The primary outcome was cumulative incidence of in-hospital death.ResultsAmong propensity score-matched patients in the anticoagulation cohort (N = 382), in a multivariable regression model, intermediate-compared to prophylactic-dose anticoagulation was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.518 [0.308-0.872]). Among propensity-score matched patients in the aspirin cohort (N = 638), in a multivariable regression model, in-hospital aspirin compared to no antiplatelet therapy was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.522 [0.336-0.812]).InterpretationIn this propensity score-matched, observational study of COVID-19, intermediate-dose anticoagulation and aspirin were each associated with a lower cumulative incidence of in-hospital death.Summary conflict of interest statementsNo conflict of interest exists for any author on this manuscript.

scholarly journals Remdesivir Use in Patients Requiring Mechanical Ventilation due to COVID-19

2020 ◽  
Vol 7 (11) ◽  
Author(s):  
Giuseppe Lapadula ◽  
Davide Paolo Bernasconi ◽  
Giacomo Bellani ◽  
Alessandro Soria ◽  
Roberto Rona ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Hospital Discharge ◽  
Multivariable Analysis ◽  
Competing Risk ◽  
Lower Mortality ◽  
Hospital Death ◽  
Related Factors ◽  
Cox Models ◽  
Treatment Groups ◽  
Reduction Of Mortality

Abstract Background Remdesivir has been associated with accelerated recovery of severe coronavirus disease 2019 (COVID-19). However, whether it is also beneficial in patients requiring mechanical ventilation is uncertain. Methods All consecutive intensive care unit (ICU) patients requiring mechanical ventilation due to COVID-19 were enrolled. Univariate and multivariable Cox models were used to explore the possible association between in-hospital death or hospital discharge, considered competing-risk events, and baseline or treatment-related factors, including the use of remdesivir. The rate of extubation and the number of ventilator-free days were also calculated and compared between treatment groups. Results One hundred thirteen patients requiring mechanical ventilation were observed for a median of 31 days of follow-up; 32% died, 69% were extubated, and 66% were discharged alive from the hospital. Among 33 treated with remdesivir (RDV), lower mortality (15.2% vs 38.8%) and higher rates of extubation (88% vs 60%), ventilator-free days (median [interquartile range], 11 [0–16] vs 5 [0–14.5]), and hospital discharge (85% vs 59%) were observed. Using multivariable analysis, RDV was significantly associated with hospital discharge (hazard ratio [HR], 2.25; 95% CI, 1.27–3.97; P = .005) and with a nonsignificantly lower mortality (HR, 0.73; 95% CI, 0.26–2.1; P = .560). RDV was also independently associated with extubation (HR, 2.10; 95% CI, 1.19–3.73; P = .011), which was considered a competing risk to death in the ICU in an additional survival model. Conclusions In our cohort of mechanically ventilated patients, RDV was not associated with a significant reduction of mortality, but it was consistently associated with shorter duration of mechanical ventilation and higher probability of hospital discharge, independent of other risk factors.

scholarly journals Clinical course and severity outcome indicators among COVID 19 hospitalized patients in relation to comorbidities distribution Mexican cohort

2020 ◽  
Author(s):  
Genny Carrillo ◽  
Nina Mendez Dominguez ◽  
Kassandra D Santos Zaldivar ◽  
Andrea Rochel Perez ◽  
Mario Azuela Morales ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Respiratory Diseases ◽  
Risk Estimation ◽  
Clinical Manifestations ◽  
Case Fatality ◽  
Hospitalized Patients ◽  
Hospital Death ◽  
Outcome Indicators

Introduction: COVID-19 affected worldwide, causing to date, around 500,000 deaths. In Mexico, by April 29, the general case fatality was 6.52%, with 11.1% confirmed case mortality and hospital recovery rate around 72%. Once hospitalized, the odds for recovery and hospital death rates depend mainly on the patients' comorbidities and age. In Mexico, triage guidelines use algorithms and risk estimation tools for severity assessment and decision-making. The study's objective is to analyze the underlying conditions of patients hospitalized for COVID-19 in Mexico concerning four severity outcomes. Materials and Methods: Retrospective cohort based on registries of all laboratory-confirmed patients with the COVID-19 infection that required hospitalization in Mexico. Independent variables were comorbidities and clinical manifestations. Dependent variables were four possible severity outcomes: (a) pneumonia, (b) mechanical ventilation (c) intensive care unit, and (d) death; all of them were coded as binary Results: We included 69,334 hospitalizations of laboratory-confirmed and hospitalized patients to June 30, 2020. Patients were 55.29 years, and 62.61% were male. Hospital mortality among patients aged<15 was 9.11%, 51.99% of those aged >65 died. Male gender and increasing age predicted every severity outcome. Diabetes and hypertension predicted every severity outcome significantly. Obesity did not predict mortality, but CKD, respiratory diseases, cardiopathies were significant predictors. Conclusion: Obesity increased the risk for pneumonia, mechanical ventilation, and intensive care admittance, but it was not a predictor of in-hospital death. Patients with respiratory diseases were less prone to develop pneumonia, to receive mechanical ventilation and intensive care unit assistance, but they were at higher risk of in-hospital death.

scholarly journals Evaluation of the Prothrombin Fragment 1.2 in Patients with COVID-19

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 4-5
Author(s):  
Hanny Al-Samkari ◽  
Fei Song ◽  
Elizabeth M. Van Cott ◽  
David J. Kuter ◽  
Rachel P. Rosovsky
Keyword(s):  
Critically Ill ◽  
Research Funding ◽  
Roc Analysis ◽  
Hospitalized Patients ◽  
Thrombotic Complication ◽  
Prothrombin Fragment ◽  
Therapeutic Anticoagulation ◽  
Platelet Disorder ◽  
Multivariable Regression ◽  
D Dimer

Introduction: Coronavirus disease 2019 (COVID-19) may cause a hypercoagulable state. The D-dimer is frequently elevated in COVID-19, but other markers of coagulation activation, including the prothrombin fragment 1.2 (PF1.2) are poorly described. Given the near universal D-dimer elevation in critically ill patients with COVID-19, the PF1.2 may be a more specific marker to identify thrombotic complications. Methods: We studied hospitalized adults with COVID-19 and PF1.2 measurement performed at any point during hospitalization. We evaluated the relationship between PF1.2 and synchronously measured D-dimer. We utilized receiver operating characteristic (ROC) analysis to evaluate optimal thresholds for diagnosing thrombosis and multivariable logistic regression to evaluate association with thrombosis. Thresholds for each assay for multivariable regression were determined from ROC analysis. To avoid confounding of therapeutic anticoagulation on PF1.2 or D-dimer measurement, patients receiving therapeutic anticoagulation at the time of assay measurement were excluded from these analyses. Results: Patients and Thrombotic Events. 115 hospitalized patients with COVID-19 were included [110 (95.7%) critically ill], encompassing 3318 patient-days (474 patient-weeks) analyzed for thrombotic and critical illness complications. At the data cutoff date, 74 patients (64.3%) had been discharged from the hospital alive, 24 patients (20.9%) died in the hospital, and 17 patients (14.8%) remained hospitalized, having been hospitalized for a median of 44 (range, 30-62) days. Over a median follow-up of 29 (range, 2-62) hospital days, 26 patients developed radiographically-confirmed VTE (22.6%, a rate of 5.49 per 100 patient-weeks); including arterial, extracorporeal circuit, and recurrent line thrombosis, 56 patients (48.7%) developed a thrombotic complication. At the time of PF1.2 and synchronous D-dimer measurement, 37 patients (32.1%) were receiving therapeutic anticoagulation, 77 patients (67.0%) were receiving prophylactic anticoagulation, and 1 patient (0.9%) was not receiving pharmacologic thromboprophylaxis. Association of PF1.2 with D-dimer. Synchronously measured PF1.2 and D-dimer were moderately positively correlated (r=0.542, P&lt;0.001, Figure 1) but significant discordance was observed in elevation of each marker above the laboratory reference range (59.0% patients with elevated PF1.2 vs. 98.5% elevated D-dimer). Association of PF1.2 with Hypercoagulability. Median PF1.2 levels were higher in patients with thrombosis than those without (611 vs. 374 pmol/L, P=0.006, Figure 2). Therapeutic anticoagulation suppressed median PF1.2 levels: median (IQR) PF1.2 in patients not receiving therapeutic anticoagulation (N=29) was 611 pmol/L (333-1148 pmol/L), significantly higher than the median (IQR) PF1.2 in patients receiving therapeutic anticoagulation (N=27) of 347 pmol/L (195-506 pmol/L), P=0.0017. ROC and Multivariable Regression Analyses. In ROC analysis, PF1.2 had superior specificity and conferred a higher positive likelihood ratio in identifying patients with thrombosis than did the D-dimer (PF1.2 threshold of &gt;523 pmol/L: 69.2% sensitivity, 67.7% specificity; &gt;924 pmol/L: 37.9% sensitivity, 87.8% specificity, Figure 3). In multivariable analysis controlling for age, sex, and BMI, a PF1.2 &gt;500 pmol/L was significantly associated with VTE [adjusted odds ratio (OR) 4.26, 95% CI, 1.12-16.21, P=0.034] and any thrombotic manifestation (adjusted OR 3.85, 95% CI, 1.39-10.65, P=0.010); conversely, synchronously measured D-dimer &gt;2,500 ng/mL was not significantly associated with VTE (OR 5.91, 95% CI, 0.69-50.56, P=0.11) or any thrombotic manifestation (OR 2.47, 95% CI, 0.78-7.78, P=0.12). The vast majority (90.6%) of patients with a non-elevated PF1.2 result did not develop VTE and 75% did not develop any thrombotic complication. Conclusions: When measured at any point during hospitalization in patients not receiving therapeutic anticoagulation, PF1.2 was more specific than synchronously measured D-dimer in identifying patients who experienced thrombosis and was significantly associated with thrombotic manifestations in multivariable analyses while the D-dimer was not. PF1.2 may be a useful assay, and potentially more discriminant than D-dimer, in identifying thrombotic manifestations in hospitalized patients with COVID-19. Disclosures Al-Samkari: Rigel: Consultancy; Agios: Consultancy, Research Funding; Argenx: Consultancy; Amgen: Research Funding; Dova: Consultancy, Research Funding. Kuter:Caremark: Consultancy, Honoraria; Immunovant: Other: Travel Expenses, Research Funding; CRICO: Consultancy, Honoraria; UCB: Consultancy, Honoraria; Up-To-Date: Consultancy, Honoraria, Patents & Royalties; Zafgen: Consultancy, Honoraria; Sanofi (Genzyme): Consultancy, Honoraria; Shionogi: Consultancy, Honoraria; Shire: Consultancy, Honoraria; Shionogi: Consultancy; Protalix Biotherapeutics: Consultancy; Principia: Consultancy, Research Funding; Protalex: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Other: Travel Expenses, Research Funding; Alnylam: Consultancy, Honoraria, Other: Travel Expenses, Research Funding; Agios: Consultancy, Honoraria, Other: Travel Expenses, Research Funding; Daiichi Sankyo: Consultancy, Honoraria; Actelion (Syntimmune): Consultancy, Honoraria, Other: Travel Expenses, Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria, Other: Travel Expenses, Research Funding; Argenx: Consultancy, Honoraria, Other: Travel Expenses, Research Funding; Kezar Life Sciences, Inc: Other, Research Funding; Platelet Disorder Support Association: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Momenta: Consultancy, Honoraria; Merck Sharp Dohme: Consultancy, Honoraria; Rigel: Consultancy, Honoraria, Other, Research Funding; Takeda (Bioverativ): Consultancy, Honoraria, Other, Research Funding; Dova: Consultancy, Honoraria; Genzyme: Consultancy, Honoraria; Immunovant: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Kyowa-Kirin: Consultancy, Honoraria; Protalex: Consultancy, Honoraria, Other, Research Funding; Principia Biopharma: Consultancy, Honoraria, Other, Research Funding. Rosovsky:Bristol-Myers Squibb, Dova, Janssen, Portola: Consultancy; Bristol-Myers Squibb, Janssen: Research Funding.

scholarly journals How COVID-19 has changed medical research funding

2021 ◽  
Vol 11 (6) ◽  
Author(s):  
Patrick F. Chinnery ◽  
Jonathan J. Pearce ◽  
Anna M. Kinsey ◽  
Joanna M. Jenkinson ◽  
Glenn Wells ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Medical Research ◽  
Research Funding ◽  
Government Funding ◽  
Research Community ◽  
Hospitalized Patients ◽  
Look Back ◽  
Uk Government ◽  
Long Term Impact

Here, we consider how the lessons we learned in 2020 from funding COVID-19 research could have a long-term impact on the way that we fund medical research. We look back at how UK government funding for COVID-19 medical research evolved, beginning with the early calls for proposals in February that pump-primed funding for vaccines and therapeutics, and culminating in the launch of the government's National Core Studies programme in October. We discuss how the research community mobilized to submit and review grants more rapidly than ever before, against a background of laboratory and office closures. We also highlight the challenges of running clinical trials as the number of hospitalized patients fluctuated with different waves of the disease.

scholarly journals Competing risk and heterogeneity of treatment effect in clinical trials

Trials ◽  
2008 ◽  
Vol 9 (1) ◽  
Author(s):  
David M Kent ◽  
Alawi Alsheikh-Ali ◽  
Rodney A Hayward
Keyword(s):  
Clinical Trials ◽  
Treatment Effect ◽  
Competing Risk ◽  
Heterogeneity Of Treatment Effect

scholarly journals Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Bo Yu ◽  
Victor Perez Gutierrez ◽  
Alex Carlos ◽  
Gregory Hoge ◽  
Anjana Pillai ◽  
...  
Keyword(s):  
Mechanical Ventilation ◽  
Propensity Score ◽  
Propensity Score Matching ◽  
Major Bleeding ◽  
Risk Estimation ◽  
Large Population ◽  
Invasive Mechanical Ventilation ◽  
Bleeding Risk ◽  
Hospitalized Patients ◽  
Significant Difference

Abstract Background Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016). Conclusion Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

scholarly journals Clinical effectiveness of convalescent plasma in hospitalized patients with COVID-19: a systematic review and meta-analysis

2021 ◽  
Vol 15 ◽  
pp. 175346662110280
Author(s):  
Roberto Ariel Abeldaño Zuñiga ◽  
Ruth Ana María González-Villoria ◽  
María Vanesa Elizondo ◽  
Anel Yaneli Nicolás Osorio ◽  
David Gómez Martínez ◽  
...  
Keyword(s):  
Systematic Review ◽  
Clinical Trials ◽  
Clinical Improvement ◽  
Data Extraction ◽  
Meta Analysis ◽  
Clinical Effectiveness ◽  
Risk Of Bias ◽  
Hospitalized Patients ◽  
Low Risk ◽  
Controlled Clinical Trials

Aims: Given the variability of previously reported results, this systematic review aims to determine the clinical effectiveness of convalescent plasma employed in the treatment of hospitalized patients diagnosed with COVID-19. Methods: We conducted a systematic review of controlled clinical trials assessing treatment with convalescent plasma for hospitalized patients diagnosed with SARS-CoV-2 infection. The outcomes were mortality, clinical improvement, and ventilation requirement. Results: A total of 51 studies were retrieved from the databases. Five articles were finally included in the data extraction and qualitative and quantitative synthesis of results. The overall risk of bias in the reviewed articles was established at low-risk only in two trials. The meta-analysis suggests that there is no benefit of convalescent plasma compared with standard care or placebo in reducing the overall mortality and the ventilation requirement. However, there could be a benefit for the clinical improvement in patients treated with plasma. Conclusion: Current results led to assume that the convalescent plasma transfusion cannot reduce the mortality or ventilation requirement in hospitalized patients diagnosed with SARS-CoV-2 infection. More controlled clinical trials conducted with methodologies that ensure a low risk of bias are still needed. The reviews of this paper are available via the supplemental material section.

scholarly journals 34 Discharge After Hip Fracture Surgery by Mobilisation Timing: Secondary Analysis of the UK National Hip Fracture Database

2021 ◽  
Vol 50 (Supplement_1) ◽  
pp. i7-i11
Author(s):  
A Goubar ◽  
O Almilaji ◽  
F C Martin ◽  
C Potter ◽  
G D Jones ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Average Rate ◽  
Small Sample Size ◽  
Small Sample ◽  
Competing Risk ◽  
Hospital Death ◽  
Early Mobilisation ◽  
Hip Fracture Surgery ◽  
Risk Of Death ◽  
Fracture Surgery

Abstract Background To maximise the benefits of hip fracture surgery the National Institute for Health and Care Excellence Clinical Guideline recommends mobilisation on the day after hip fracture surgery based a low to moderate quality trial with a small sample size. There is a need to generate additional evidence to support early mobilisation as a new UK Best Practice Tariff (BPT). Objective To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30-days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death. Method We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between January 2014 and December 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36 hours of surgery) and those mobilised late accounting for potential confounders and the competing risk of in-hospital death. Results 106,722 (79%) of patients first mobilised early. The average rate of discharge was 60.1 (95% CI 59.8–60.5) per 1,000 patient days, varying from 65.2 (95% CI 64.8–65.6) among those who mobilised early to 44.5 (95% CI 43.9–45.1) among those who mobilised late, accounting for the competing risk of death. By 30-days postoperatively, the crude and adjusted odds ratios of discharge were 2.26 (95% CI 2.2–2.32) and 1.93 (95% CI 1.86–1.99) respectively among those who first mobilised early compared to those who mobilised late, accounting for the competing risk of death. Conclusion Early mobilisation led to a near two fold increase in the adjusted odds of discharge by 30-days postoperatively. We recommend inclusion of mobilisation within 36 hours of surgery as a new UK BPT to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture.

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