Trends in Comorbidities and Complications Among Patients Undergoing Hip Fracture Repair

Janis Bekeris, MD; Lauren A. Wilson, MPH; Dace Bekere, MD; Jiabin Liu, MD, PhD; Jashvant Poeran, MD, PhD; Nicole Zubizarreta, MPH; Megan Fiasconaro, MS; Stavros G. Memtsoudis, MD, PhD, MBA


Anesth Analg. 2021;132(2):475-484. 

In This Article

Abstract and Introduction


Background: Hip fracture patients represent various perioperative challenges related to their significant comorbidity burden and the high incidence of morbidity and mortality. As population trend data remain rare, we aimed to investigate nationwide trends in the United States in patient demographics and outcomes in patients after hip fracture repair surgery.

Methods: After Institutional Review Board (IRB) approval (IRB#2012-050), data covering hip fracture repair surgeries were extracted from the Premier Healthcare Database (2006–2016). Patient demographics, comorbidities, and complications, as well as anesthesia and surgical details, were analyzed over time. Cochran–Armitage trend tests and simple linear regression assessed significance of (linear) trends.

Results: Among N = 507,274 hip fracture cases, we observed significant increases in the incidence in preexisting comorbid conditions, particularly the proportion of patients with >3 comorbid conditions (33.9% to 43.4%, respectively; P < .0001). The greatest increase for individual comorbidities was seen for sleep apnea, drug abuse, weight loss, and obesity. Regarding complications, increased rates over time were seen for acute renal failure (from 6.9 to 11.1 per 1000 inpatient days; P < .0001), while significant decreasing trends for mortality, pneumonia, hemorrhage/hematoma, and acute myocardial infarction were recorded. In addition, decreasing trends were observed for the use of neuraxial anesthesia either used as sole anesthetic or combined with general anesthesia (7.3% to 3.6% and 6.3% to 3.4%, respectively; P < .0001). Significantly more patients (31.9% vs 41.3%; P < .0001) were operated on in small rather than medium- and large-sized hospitals.

Conclusions: From 2006 to 2016, the overall comorbidity burden increased among patients undergoing hip fracture repair surgery. Throughout this same time period, incidence of postoperative complications either remained constant or declined with the only significant increase observed in acute renal failure. Moreover, use of regional anesthesia decreased over time. This more comorbid patient population represents an increasing burden on the health care system; however, existing preventative measures appear to be effective in minimizing complication rates. Although, given the proposed benefits of regional anesthesia, decreased utilization may be of concern.


Hip fracture is a serious public health problem associated with complications and substantial cost.[1–3] Studies report rather broad incidence rates worldwide ranging from 1.2 to 5.6 per 10,000 in Africa to almost 40 per 10,000 in Scandinavian countries and 126.9 per 10,000 in Italy.[4] With increased life expectancy, advances in medical care, and improved public health initiatives, studies suggest that along with the aging population the total number of patients with hip fractures will increase by approximately 2% annually over the next 30 years.[2] The average annual cost of hip fracture in the United States is estimated to be over $12 billion, creating a significant financial burden on the health care system.[5]

Adding to the overall impact on health care systems worldwide are relatively high complication rates with postoperative 1-year mortality reaching 35%,[6–9] as well as high comorbidity burden among patients with hip fracture.[2,7,10–12] Despite this significant impact on population health, recent large-scale data on trends are lacking. Identifying such trends in patient and health care system–related aspects of hip fracture care is important to adjust care delivery and allocate resources effectively.[12–14] To this end, we used national (United States) data to identify changes in patient-related characteristics (including comorbidities) as well as health care–related factors such as changes in anesthetic practice and postoperative outcomes among hip fracture repair patients over an 11-year time period. We hypothesized that significant trends could be identified, which could be used to focus interventions and research as well as allocate resources to improve postoperative outcomes.