Rev Esp Salud Pública. 2019; Vol. 93: October 18th e1-15. www.msc.es/resp Received: May 15th 2019 ORIGINAL Accepted: July 23rd 2019 Published: October 18th 2019 SPANISH NATIONAL HIP FRACTURE REGISTRY (RNFC): FIRST-YEAR RESULTS AND COMPARISON WITH OTHER REGISTRIES AND PROSPECTIVE MULTICENTRIC STUDIES FROM SPAIN(*) Pilar Sáez-López (1,2), Cristina Ojeda-Thies (3), Teresa Alarcón (2,4), Angélica Muñoz Pascual (5), Jesús Mora-Fernández (6), Cristina González de Villaumbrosia (7), María Jesús Molina Hernández (8), Nuria Montero-Fernández (9), José Manuel Cancio Trujillo (10), Adolfo Díez Pérez (11,12), Daniel Prieto Alhambra (13, 14), José Ramón Caeiro Rey (15), Íñigo Etxebarria Foronda (16), Paloma Gómez Campelo (2,17), Teresa Pareja Sierra (18), Francisco José Tarazona-Santabalbina (19, 20), Rosario López-Giménez (21), Ángel Otero Puime (21), Laura Navarro-Castellanos (2), Rocío Queipo Matas (22), Sonia Jiménez Mola (23), Tomás López-Peña (24), Concepción Cassinello Ogea (25) and Juan I. González-Montalvo (2,4) representing the participants of the RNFC (1) Unidad de Geriatría. Hospital Universitario Fundación Alcorcón. Alcorcón. Spain. (2) Instituto de Investigación del Hospital Universitario La Paz, “IdiPaz”. Madrid. Spain. (3) Servicio de Traumatología y Cirugía Ortopédica. Hospital Universitario 12 de Octubre. Madrid. Spain. (4) Servicio de Geriatría. Hospital Universitario La Paz. Madrid. Spain. (5) Sección de Geriatría. Complejo Asistencial de Segovia. Segovia. Spain. (6) Servicio de Geriatría, IdISSC. Hospital Universitario Clínico San Carlos. Madrid. Spain. (7) Servicio de Geriatría. Hospital Universitario Rey Juan Carlos. Móstoles. Spain. (8) Servicio de Geriatría. Hospital Universitario Severo Ochoa. Leganés. Spain. (9) Servicio de Geriatría. Instituto de Investigación Sanitaria Gregorio Marañón. Hospital Universitario Gregorio Marañón. Madrid. Spain. (10) Centro Sociosanitario El Carme. Servicio de Geriatría y Cuidados Paliativos de BSA (Badalona Servicios Asistenciales). Badalona. Spain. (11) Hospital del Mar y Universidad Autónoma de Barcelona. Barcelona. Spain. (12) CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES). Instituto Carlos III. Madrid. Spain. (13) NDORMS, Grupo de Investigación GREMPAL, Idiap Jordi Gol y CIBERFes. University of Oxford. Oxford. United Kingdom. (14) Universitat Autònoma de Barcelona e Instituto de Salud Carlos III. Barcelona. Spain. (15) Servicio de Cirugía Ortopédica y Traumatología. Complejo Hospitalario Universitario de Santiago. Departamento de Cirugía. Universidad de Santiago de Compostela. Santiago de Compostela. Spain. (16) Hospital Alto Deba. Arrasate/Mondragón. Spain. (17) Centro de Ciencias de la Salud San Rafael. Universidad Antonio de Nebrija. Madrid. Spain. (18) Servicio de Geriatría. Hospital Universitario de Guadalajara. Guadalajara. Spain. (19) Servicio de Geriatría. Hospital Universitario de La Ribera. Alzira. Spain. (20) Hamad Medical Corporation. Doha. Qatar. (21) Departamento de Medicina Preventiva y Salud Pública. Universidad Autónoma de Madrid. Madrid. Spain. (22) Universidad Europea de Madrid. Madrid. Spain. (23) Servicio de Geriatría. Complejo Asistencial Universitario de León. León. Spain. (24) Subdirección General de Programas Internacionales de Investigación y Relaciones Institucionales. Instituto de Salud Carlos III. Madrid. Spain. (25) Servicio de Anestesiología y Reanimación. Hospital Universitario Miguel Servet. Zaragoza. Spain. Authors declare that there is no conflict of interest. (*) Financing: The RNFC has been financed through donations by AMGEN SA, UCB Pharma, Abbott Laboratories and FAES Farma, as well as a Research Grant from the Fundación Mutua Madrileña (AP169672018). The sponsors did not influence any aspect of the project nor of the drafting of this manuscript. Suggested citation: Sáez-López P, Ojeda-Thies C, Alarcón T, Muñoz Pas- cual A, Mora-Fernández J, González de Villaumbrosia C, Molina Hernández MJ, Montero-Fernández N, Cancio Trujillo JM, Díez Pérez A, Prieto Alhambra Correspondence: D, Caeiro Rey JR, Etxebarria Foronda I, Gómez Campelo P, Pareja Sierra T, Pilar Sáez López Tarazona-Santabalbina FJ, López-Giménez R, Otero Puime A, Navarro-Cas- Unidad de Geriatría tellanos L, Queipo Matas R, Jiménez Mola S, López-Peña T, Cassinello Ogea Hospital Universitario Fundación Alcorcón C, González-Montalvo JI. Spanish National Hip Fracture Registry (rnfc): Calle Budapest, 1 first-year results and comparison with other registries and prospective mul- 28922 Alcorcón, Madrid ticentric studies from Spain. Rev Esp Salud Pública. 2019;93: October 18th pisalop@gmail.com e201910072. Rev Esp Salud Pública. 2019; Vol. 93: 20 de octubre e1-XX. www.msc.es/resp ABSTRACT RESUMEN Registro Nacional de Fracturas Background: The Spanish National Hip de Cadera (RNFC): resultados del primer año y comparación con otros registros Fracture Registry (Registro Nacional de Fracturas y estudios multicéntricos españoles. de Cadera or RNFC) is a Spanish, prospective, mul- ti-centric registry, commenced in 2017. The goal of Fundamentos: El Registro Nacional de this paper is to present the data from the first annual Fracturas de Cadera (RNFC) es un registro español report and to compare them with autonomic regis- multicéntrico, prospectivo y continuo, que comen- tries and recent prospective multi-centric studies zó en 2017. El objetivo de este artículo fue presen- performed in Spain. tar los datos del primer informe anual y comparar- Methods: We included persons 75 years of age los con los registros autonómicos y los estudios or older treated for fragility hip fractures in any multicéntricos realizados recientemente en España. of the centers participating in the RNFC between Métodos: Se incluyeron las personas de 75 January and October 2017. The descriptive statis- años o más atendidas con el diagnóstico de fractura tics of each variable used the mean (and standard de cadera por fragilidad en alguno de los hospitales deviation) or the median (and interquartile ranges) participantes en el RNFC, entre enero y octubre de for the ordinal variables and the percentage for the 2017. En el análisis estadístico se utilizó la media y categoric variables. A descriptive analysis of the ca- desviación estándar o mediana y rangos intercuartí- semix was performed and compared with available licos para las variables numéricas y los porcentajes data from the aforementioned studies. para las variables categóricas. Se realizó un análi- Results: The RNFC included 7.208 patients sis descriptivo global de la casuística y se compa- from 54 hospitals, with a mean age of 86.7 (SD ró con los datos disponibles de los estudios previos 5.6) years; 75.4% were women, and 36.4% showed mencionados. cognitive decline. Mean surgical delay was 75.7 Resultados: Se registraron 7.208 personas de (SD 63.6) hours, and length of stay averaged 10.9 54 hospitales, con una edad media de 86,7 años (SD 6.7) days. Of the patients who lived at home (DE 5,6). El 75,4% fueron mujeres y el 36,4% (75.4%), less than half (37.0%) returned home presentaron deterioro cognitivo previo. La demo- at discharge. One-month mortality was 7.1%. ra quirúrgica media fue de 75,7 horas (DE 63,6) Comparison with other studies showed important y la estancia media fue de 10,9 días (DE 6,7). De differences, especially regarding patients newly las personas que vivían en un domicilio antes de la sent to nursing homes (7.7-29.4%) and with anti- fractura (75,4%), menos de la mitad (37,0%) vol- osteoporotic treatment at discharge (14.5-36.7%). vieron a él tras el alta hospitalaria. Al mes, había Conclusions: The RNFC is the largest pros- fallecido el 7,1%. La comparación con los otros es- pective database to date that offers data regarding tudios mostró algunas diferencias importantes, so- the characteristics of patients hospitalized for hip bre todo en la ubicación previa, en el porcentaje de fractures in Spain. Comparison with recent studies pacientes institucionalizados de novo (7,7-29,4%) showed some important differences. y en el porcentaje con tratamiento antiosteoporóti- Key words: Hip fractures, Osteoporosis, co al alta (14,5-36,7%). Registries, Elderly Conclusiones: El RNFC es la mayor base de datos prospectiva que aporta datos sobre el perfil de los pacientes hospitalizados por fractura de ca- dera en España. La comparación con otros estudios recientes muestra algunas diferencias importantes. Palabras clave: Fractura de cadera, Osteo- porosis, Registros, Anciano 2 Pilar Sáez-López et al INTRODUCTION publications in the last decades(18), but was lacking a national hip fracture registry. Several Fragility hip fractures (HF) occur as a conse- regional registries and recent multi-centric quence of falls from standing height. They are studies have been carried out, with different an important health issue, due to their growing objectives and methodology. Data regarding frequency in an aging society and the morbi- hip fractures treated during a time period were mortality and functional dependence they cau- collected prospectively in Castile-León, as well se(1,2,3,4). Treating these fractures costs approxi- as in Madrid(19,20). In Catalonia, a retrospective mately 1,591 million Euros annually, and a analysis was performed, crossing data included total of 7,218 quality-adjusted years of life are in several healthcare-related databases(1,21,22), lost per year(5,6). According to a report by the providing information regarding surgical Ministry of Health, the incidence in Spain was delay, survival and health expenses the year 103.76 cases per 100,000 inhabitants / year in preceding and following hip fractures treated 2008, increasing especially above 75 years of in that region. There are two other important age. More recent studies estimate that there recent multi-centric cohort studies, SPARE- are between 40,000 and 45,000 hip fractures in HIP (SPAnish REgistry of osteoporostic HIP Spain per year, and this number is foreseen to fractures)(23) and the PROA study (PRospective keep increasing, especially among persons ol- Observational study in the burden of hip der than 80 years old(4,5). frActures in Spain)(24,25). In an effort to minimize the variability in the Including many of the authors of the afore- management of these patients, and to maximize mentioned studies(1,18,19,20,21,22,23,24,25), a working efficiency, several articles and Clinical Practice group was initiated in 2016 to create a continuous Guidelines (CPGs) have been published, that national hip fracture registry in Spain, with inter- allow to consensuate and improve the manage- territorial representation. Its goals were to eva- ment of hip fractures(7,8,9,10,11,12,13). Several coun- luate the characteristics of the patients treated tries also have national registries of hip fracture and the healthcare provided to this process, as patients. The oldest one is the Swedish registry well as to provide an instrument that could be Rikshöft, established in 1986, followed by the used for continuous audit or quality control. In Scottish registry in 1993. With over 65,000 cases a later stage, national and international compari- annually, the British registry (initiated in 2007) sons were to be performed, as well as proposals collects the highest number of cases per year of of quality standards and criteria to improve qua- all the established national registries(14,15). The lity of care. From the start, the working group information extracted from these registries has was multidisciplinary, and included professio- allowed for audit of the care process, establish- nals who wished to voluntarily participate in ment of quality standards and evaluation of com- the registry, with was called Registro Nacional pliance with these standards or deviation from de Fracturas de Cadera (Spanish National Hip them, introduction of corrective measures and, Fracture Registry, RNFC). The group currently finally, improvement of the care process and effi- comprises approximately 190 professionals, ciency. Reduction of surgical delay and been de- mainly geriatricians, internists, orthopedic sur- monstrated, with a lower one-year mortality, at geons, rehabilitation specialists, anesthesiolo- least in the British registry(14,16,17). gists and nurses, all of them involved directly in the clinical management of these patients. Its ob- Spain has ample experience with integrated jectives and methodology have been published orthogeriatric care, reflected through numerous previously(26,27). 3 Rev Esp Salud Pública. 2019;93: October 18th e201910072 SPANISH NATIONAL HIP FRACTURE REGISTRY (RNFC): FIRST-YEAR RESULTS AND COMPARISON WITH OTHER REGISTRIES AND PROSPECTIVE... The goal of this study was to present the main the data and performed descriptive analyses and results of the first annual report of the RNFC and the pertinent associations to periodically elabo- compare them with those published by other re- rate reports. The project was classified by the gistries and multi-center studies previously per- Spanish Agency for Medications and Sanitary formed in Spain. Products (Agencia Española del Medicamento y Productos Sanitarios, or AEMPS), as no-EPA MATERIAL AND METHODS (non-postauthorization study), and followed the rules of the 2013 Declaration of Helsinki. Spanish National Hip Fracture Registry (RNFC). The RNFC includes all people aged 75 years or The results presented in this publication above admitted to the participating hospitals are a summary of the data corresponding to with the diagnosis of a fragility hip fracture. the patients included between January and October 2017, comprising the First Annual Data was collected in agreement with the Report of the RNFC. A descriptive analysis Spanish version of the Minimum Common of the information was performed, calculating Dataset or FFN-MCD, the minimum common da- the means and standard deviations of quantita- taset proposed by the Fragility Fracture Network, tive variables, and the percentages of the cate- an international society dedicated to the study and gorical variables. improvement of fragility fracture care(26,28). The FFN-MCD was agreed upon in 2013 by an inter- Comparison with other Spanish multi-centric national working party comprised fundamentally studies. Comparison with other Spanish regis- of representatives of existing national registries. tries was performed with the data published Its goal was to facilitate comparability of esta- by these. blished registries and to support the creation of new national registries. This FFN-MCD is conci- The autonomic registry of Castile-León was se, covers the key elements of the case-mix, care a prospective, observational multi-centric stu- process and outcome, and is compatible with pre- dy that included patients older than 74 years viously existing databases. old admitted for hip fractures in 13 public hos- pitals of that autonomous community, during The physician in charge of the patient collec- November 2014 and November and December ted the initial data during acute hospitalization, of 2015(19). after provision of informed consent for inclu- sion in the RNFC. Patients were contacted one The autonomic registry of Madrid was a month after the fracture telephonically or du- prospective, observational multi-centric study ring a follow-up visit. The project was appro- performed between 2015 and 2016, with 8 hos- ved by the local Ethics and Clinical Research pitals from the Community of Madrid that had Committees (Comités de Ética e Investigación orthogeriatric hip fracture care participating(20). Clínica or CEIC) of the participating hospitals. Each participating hospital had a physician of The study from Catalonia was a retrospective reference locally responsible for the registry. study that included data of patients 65 years old or older treated for hip fractures between 2009- Data was submitted to the RNFC every three 2011 and between 2012-2016 in Catalonia. months, in an encrypted manner. A data manager Information included in several healthcare-re- assigned an anonymous identifier to each cen- lated administrative databases (CMDB, as well ter, for analysis and later presentation, cleaned as the registries of Primary Care, socio-sanitary Rev Esp Salud Pública. 2019;93: October 18th e201910072 4 Pilar Sáez-López et al care, mental health and emergencies, insurance comparing them with data from the RNFC. The registry, pharmaceutical activity and the billing databases of the aforementioned studies were registry of CatSalut) was crossed(1,21,22). not available for statistical comparison with the RNFC. Another two prospective multi-centric and inter-regional cohort studies were analyzed. On RESULTS the one hand, the SPARE-HIP study (SPAnish Registry of osteoporotic HIP fracture) pros- The First Annual Report of the RNFC co- pectively included 30 consecutive cases from llected data of 7,208 persons aged 75 years and 45 hospitals of several autonomous commu- older with fragility hip fractures treated in 54 nities(23). On the other hand, the PROA study hospitals in 12 Autonomous Communities. The (PRospective Observational study of the bur- distribution of patients from each community is den of hip frActures in Spain) prospectively presented in table 1. included 487 patients from 6 Spanish autono- mous communities, with the goal of evaluating Profile of the patients with hip fractures the repercussion of the fractures up to one year included in the RNFC: table 2 summarizes after admission, analyzing the patients’ quality the demographic, clinical and management of life and resource use during follow-up(24,25). characteristics of the sample, and their initial evolution. The patients were a mean of 86.7 The results of these registries and studies re- (SD 5.6) years old (range: 75-108), and 75.1% ported in scientific publications were extracted, were women. The percentage of patients Table 1 Representation of the different Autonomous Communities according to the number of cases and percentage contributed to the National Hip Fracture Registry (RNFC) in 2017. Autonomous Community Number of cases % Madrid 2,423 33.6 Cataluña 1,308 18.2 Castilla y León 933 12.9 Castilla-La Mancha 919 12.8 Aragón 473 6.6 Galicia 405 5.6 Asturias 388 5.4 Andalucía 102 1.4 Extremadura 79 1.1 C. Valenciana 77 1.1 Islas Canarias 68 0.9 Murcia 33 0.5 Total 7,208 100 5 Rev Esp Salud Pública. 2019;93: October 18th e201910072 SPANISH NATIONAL HIP FRACTURE REGISTRY (RNFC): FIRST-YEAR RESULTS AND COMPARISON WITH OTHER REGISTRIES AND PROSPECTIVE... with hip fractures that had cognitive decline higher according to the American Society of (defined as 3 or more errors in Pfeiffer’s Anesthesiologists score). Questionnaire, or SPMSQ) was high (36.4%), as was that of patients with a high surgical Surgical treatment was given to 95.4% risk (67.4%, defined as an ASA III risk or of patients, usually with regional anesthesia Table 2 Patient characteristics and initial evolution of the first 7.208 cases included in the National Hip Fracture Registry (RNFC) (Data in percent, except for age, surgical delay and hospital length of stay). Characteristics Result % lost data Mean age (years) 86.7 (DE 5.6) 0 Gender (% female) 75.1 0.31 Cognitive decline (patients with SPMSQ>3) 36.4 17.4 High surgical risk (ASA ≥ 3) 67.4 5.6 Intertrochanteric 51.9 Type of fracture Subcapital 39.2 1.1 Subtrochanteric 7.2 Patients managed surgically 95.4 2.2 Cannulated screws 2 Sliding screw 1 Type of surgery Cephalomedullary nail 56.8 2.4 Hemiarthroplasty 32.5 Total hip arthroplasty 2.9 Patients operated on with regional anesthesia 88.3 5.2 Patients developing pressure ulcers during hospitalization(*) 6.4 4.4 Patients mobilized on the first postoperative day 55.9 3.1 Collaborating clinician: geriatrics / internal medicine 79.6/13.3 0.9 Surgical delay (hours) 75.7 (DE 63.6) - Hospital length of stay (days) 10.9 (DE 6.7) - Pre-fracture 82.7 1.8 Independent mobility At 30 days 58.9 1.7 Patients readmitted at 30 days(**) 2.4 11 Patients reoperated on at 30 days 2.1 12.3 Mortality at 30 days 7.1 5.8 SPMSQ: Short Portable Mental State Questionnaire de Pfeiffer; ASA: American Society of Anesthesiologists; (*) Grade 2 or above pressure ulcers; (**) Readmissions for surgical reasons; SD: Standard deviation. Rev Esp Salud Pública. 2019;93: October 18th e201910072 6 Pilar Sáez-López et al (88.3%). The most common surgical techni- later. Upon discharge from acute hospitaliza- ques performed were fixation with a cephalo- tion, 23.8% of people registered in the RNFC medullary nail (56.8%) and replacement with a were sent to geriatric rehabilitation units. One hemiarthroplasty (32.5%). Surgical delay was month mortality was 7.1%. high (75.7 hours, SD 63.6), and involved a third of the hospital length of stay, 10.9 days (SD Figure 1 shows the percentage of patients 6.7). Of the surgically treated patients, 55.9% treated with bone-protection medication, cal- were mobilized out of bed on the first posto- cium and vitamin D before the fracture, at perative day. Though 82.7% were able to walk discharge and one month after the fracture. independently (with or without aids) before the Prescription of bone-protection medication was fracture, this percentage fell to 58.9% 30 days 5% before the fracture, increased to 36.7% at after the injury. discharge, and stayed at 41% one month after the fracture. Table 3 shows the place of residence of the patients included in the RNFC before the frac- Comparison with the results of Spanish multi- ture, at discharge and at 30-day follow-up. centric studies: table 4 compares the results of One of every four (23.7%) lived in nursing ho- the RNFC with other Spanish registries and stu- mes before the fracture. Of the people living at dies. Some variables allowed for direct compa- home (75.4%), 37% returned home after dis- rison, such as age, prior walking ability, the pre- charge, and 39.3% were at home one month valence of cognitive decline, prefracture place Table 3 Place of residence of the patients included in the National Hip Fracture Registry (RNFC) before the fracture, at discharge and at 30 days (Data as percentage of total). Place of residence Pre-fracture At discharge At 30 days Home 75.4 36.9 39.3 Nursing home 23.7 31.9 29.6 Geriatric Rehabilitation Unit 0 23.8 11.9 Acute Hospitalization 0.4 1.0 2.5 Long-term care hospital 0 1.4 0.8 Deceased 0 4.4 7.1 Lost and unknown 0.4 0.5 8.9 Total 100 100 100 7 Rev Esp Salud Pública. 2019;93: October 18th e201910072 SPANISH NATIONAL HIP FRACTURE REGISTRY (RNFC): FIRST-YEAR RESULTS AND COMPARISON WITH OTHER REGISTRIES AND PROSPECTIVE... Figure 1 Percentage of patients treated with bone-protection medication before the fracture, at discharge and at one month (RNFC 2017). Before the fracture At discharge One month after Bone-protection medication Calcium Vitamin D of residence, the percentage of patients treated while length of stay did not show any important surgically and the surgical delay, the type of differences (between 10 days (Castile- León) and anesthesia, mean hospital lengths of stay, dis- 11.8 days (PROA)). One month after the fractu- charge to nursing homes, prescription of antios- re, 4.2% (SPARE-HIP) to 7.7% (Catalonia) of teoporotic treatment and in-hospital mortality. patients had died. With 7,208 cases, the RNFC was the Spanish The percentage of patients with antiosteo- prospective study providing the largest number porotic treatment at discharge oscillated from of cases. It was also the study with the highest 14.5% (Castile- León) to 36.7% (RNFC). mean age of patients. The percentage of pa- tients admitted from nursing homes varied from DISCUSSION 11.3% (PROA) to 33.4% (Castile- León), while it ranged from 25.1% (SPARE-HIP) to 63.3% This paper shows the profile of patients with (Castile- León) at discharge. The percentage of hip fracture included in the RNFC and compares patients institutionalized “de novo” varied from the registry’s results with several Spanish multi- 7.7% (SPARE-HIP) to 29.4% (Castile- León). centric studies published in the past few years. Surgical delay ranged from 2.5 days to 4 days Profile of patients with hip fractures inclu- (SPARE-HIP and Castile-León, respectively), ded in the RNFC. People with hip fractures Rev Esp Salud Pública. 2019;93: October 18th e201910072 8 Pilar Sáez-López et al Table 4 Comparison of the results of the first report of the National Hip Fracture Registry (RNFC) with those of other Spanish multi-centric hip fracture studies (Data in percentages except for age, surgical delay and length of stay). CATALONIA CASTILE- SPARE Variables (1,21,22) MADRID(20) PROA(24,25) RNFC LEÓN(19) HIP(23) Autonomic Autonomic Autonomic National National National Type of registry retrospective prospective prospective prospective prospective prospective 2009-2011(1) Inclusion period 2014-2015 2015-2016 2014-2016 2011-2012 2017 2012-2016(21.22) Number of 38,628 776 3,995 997 487 7,208 cases included Number of 62 13 8 45 28 54 participating hospitals Age of inclusion, ≥65 (84.9) ≥75 (86) (85.3) ≥50 (83.6) (83.2) ≥75 (86.7) years (mean age) Independent walking, pre-fracture / - - 68.7/- - 77.5/40.4 82.7/58.9 at discharge Patients with 21.4 37.8 37 - 19.5 36.4 cognitive decline Pre-fracture place of residence 83.4/16.6 66.6/33.4 76.2/23.8 82.1/17.4 88.5/11.3 75.4/23.7 (Home / Nursing care) Patients treated 94.6(3) 93 96.6 - 95.1 95.4 surgically Mean surgical delay 3 4 3 (median) 2.5 - 3.15 (days) Mean hospital length 11 10 11.2 11.5 11.8 10.9 of stay (days) Operated on with - 90.5 95 82.6 - 88.3 regional anesthesia (%) Destination at discharge: 49.3/25.1/ 36.9/31.9/ 55/19/12 36.6/63.3/0 -/-/40.2 - Home / NC / GRU 13.9 23.8 New institutionalization 10.5 29.4 9.8 7.7 - 13.6 Prior antiosteoporotic 4.7 - - - 15.6 5% treatment Antiosteoporotic - 14.5 - 21.4 36.7 treatment at discharge Mortality (in-hospital / 4.5/7.7 4.6 5.3 2.1/4.2 15.8 (year) 4.4/7.1 at 30 days) Collaborating clinician - 100 (100) 100 (100) 61.9 (35.3) - 92.9 (79.6) (Geriatrician) NC: Nursing care; GRU: Geriatric rehabilitation unit. 9 Rev Esp Salud Pública. 2019;93: October 18th e201910072 SPANISH NATIONAL HIP FRACTURE REGISTRY (RNFC): FIRST-YEAR RESULTS AND COMPARISON WITH OTHER REGISTRIES AND PROSPECTIVE... included in the Spanish RNFC were mainly Finally, the percentage of patients in whom women of very advanced age, with a high antiosteoporotic treatment, indicated in several surgical risk and an elevated percentage of guidelines as secondary prevention following previous cognitive decline. These characte- a hip fracture(33,34), is prescribed is lower than ristics, that can worsen prognosis, could be recommended. An analysis of the factors in- more prevalent in this study as it included fluencing the initiation of secondary prevention only patients older than 74 years of age, whi- following fragility hip fractures among the pa- le other studies included people older than 50 tients included in the RNFC is underway. or 65 years of age. A quarter of them lived in nursing homes before the fracture, and among Regarding the distribution of the number of those living at home, less than half of them patients which each region contributes to the could return home after discharge from hos- RNFC, we wish to highlight the high partici- pital. Almost all patients are treated surgica- pation of the autonomous communities with lly, and, in spite of a high surgical delay, hos- previous experience in carrying out regional pital length of stay is quite constrained. Lack registries, like Madrid, Catalonia and Castile- of treatment of osteoporosis before the frac- León(19,20,21,22). ture is the rule, though initiation of treatment at discharge is common. In spite of the efforts Comparison of the results of the RNFC with of surgical treatment and early mobilization, Spanish multi-centric studies. The RNFC’s re- and of many patients being transferred to ge- sults have been compared with those of another riatric rehabilitation units, a large percentage five multi-centric studies previously perfor- does not recover the ability to walk indepen- med in Spain, all of them prospective(19,20,23,24,25), dently one month after the fracture. except for the one done in Catalonia(1,21,22), in which information was captured from several The simple description of these results existing administrative databases. exposes some weak points of the hip frac- ture care process among the participating Most of the variables related to the patient hospitals, and suggests possible areas of im- casemix (age, presence of cognitive decline, provement. According to the Organization for pre-fracture place of residence) and many va- Economic Co-operation and Development, riables describing the care process and outcome Spain is among the countries with the lowest (percentage of surgical management and regio- proportion of patients with his fractures ope- nal anesthesia performed, surgical delay, hospi- rated on in less than 48 hours, standard recom- tal length of stay, in-hospital mortality) did not mended by several clinical practice guideli- differ much between the registries. nes(7,8,9,10,11,12,13). Increasing the percentage of patients mobilized on the first postoperative Nevertheless, differences can be observed in day would also be desirable, from the current some aspects. First, the option to transfer pa- 58,5% to values around 69-89%, as occurs in tients to geriatric rehabilitation units is prac- other countries(15). Another goal would be to tically nonexistent in Castile- León, and this improve access to functional rehabilitation, to is the reason why perhaps this community minimize the loss of autonomy observed. In showed the highest percentage of new admis- that sense, an analysis of the factors associa- sions to nursing homes. Second, the percenta- ted with functional decline following a fractu- ge of patients living in nursing homes before re is planned(30,31,32). the fracture was higher in the regional registries Rev Esp Salud Pública. 2019;93: October 18th e201910072 10 Pilar Sáez-López et al (33% and 23,8% in Castile- León and Madrid, number of cases (30 cases per center(23)). The respectively) and in the RNFC (23,7%) than continuous character of the RNFC makes it an in the multi-centric SPARE-HIP, PROA and instrument for audit, allowing for evaluation of Catalan studies (17,4%, 11,3% and 16,6%, res- models of clinical care and outcomes (globally, pectively). This detail is important, because it and for each center individually) over time. It is known that institutionalized patients usually is expected that comparison of results among have a higher functional and cognitive decline, hospitals, even blinded, would incentivize imi- conditioning their prognosis(35,36). The RNFC tation of best clinical practices, as well as eva- has the vocation of including all of the cases luation of the differences existing between au- treated in the participating centers in a conti- tonomous communities. nuous manner, through which selection bias is expected to be avoided. Finally, the percentage Another characteristic of the RNFC diffe- of patients with anti-osteoporotic medication at rentiating it form other studies previously ca- discharge is much larger in the RNFC than in rried out in Spain is the existence of follow- the other studies. This could be due to greater up, absent in the registries of Castile- León awareness in light of the results of the previous and Madrid. Analysis of the situation at one studies, as well as a participation bias, as parti- month provides information regarding impor- cipation in the RNFC is voluntary and it could tant outcome measures, such as recovery of the be expected that the participating clinicians are ability to walk, return to home, the readmission more interested in secondary prevention of fra- and reoperation rates, an one-month mortality. gility fractures. Use of the FFN-MCD allows for comparison The RNFC differentiates itself from the other of the results of the Spanish hospitals with tho- studies by its large number of cases and of cen- se of other countries that follow the recommen- ters included, its continuous nature (which in- dations of this network and use their database. cludes a follow-up phase), its vocation for cli- The other multi-centric studies do not allow for nical audit and improvement of quality of care, this possibility, since they use unshared databa- and the use of an internationally consensua- ses, limiting their direct comparability. In this ted database. It is also differs from other sys- sense, the first comparison of the data collec- tems that classify and capture patient informa- ted by the RNFC with that observed with esta- tion, such as the Minimum Common Database blished registries from another 13 countries has Set (Conjunto Mínimo de Bases de Datos, or been published(15). CMBD), because these do not include common clinical or functional variables that can condi- An important achievement of the RNFC tion the patients’ prognosis(30), nor do they allow is having formed a working group of nearly for clinical follow-up, in contrast to the RNFC. 200 healthcare professionals, originating from most autonomous communities, involved in Information from the First Annual Report of the clinical management of patients with hip the RNFC makes it the registry with the hig- fractures, with the shared goal of improving hest number of patients and hospitals of the re- quality of care. It is also a group of experts cent prospective analyses performed in Spain. who come into contact with each other, share Furthermore, the number of cases included is information, organize and/or participate in growing, as it is a continuous registry, while educational activities and research projects. the other studies were limited in time (between All this is an innovative project to acquire best 3-4 months(19,23) and 2 years(20)), or to a small clinical practices, culminating in continuous 11 Rev Esp Salud Pública. 2019;93: October 18th e201910072 SPANISH NATIONAL HIP FRACTURE REGISTRY (RNFC): FIRST-YEAR RESULTS AND COMPARISON WITH OTHER REGISTRIES AND PROSPECTIVE... audit and comparative evaluation, possible shows some similarities in the patient characteris- thanks to the RNFC. In line with this, a series tics and the care process, but also highlights diffe- of indicators and standards to improve quality rences between autonomous communities, such of care have been proposed(37). The variability of as the likelihood of returning home or receiving the processes and outcomes among hospitals and secondary prevention of fractures. the different autonomous communities is also planned to be analyzed by means of a multilevel The numerous group of participants and re- analysis. searchers of the RNFC are convinced that it is not only possible but necessary to improve A weakness of the RNFC is that, in spite of the care and the results following a hip frac- already having a large number of participating ture and, consequently, the lives of those who hospitals, it is still far from including all of the suffer one. This group wishes that this publica- hospitals in the country. Several new hospi- tion serve as an invitation to participate in the tals have started participating throughout 2018, RNFC, given its vocation to include the largest also from autonomous communities previously number of patients with fragility fractures pos- not represented (Basque Country, Navarre and sible throughout the Spanish territory. the Balearic Islands). The 7.208 cases analyzed in this study are an important proportion of the REFERENCES 40.000 to 45.000 cases that occur each year in Spain(5). Comparisons with the national CMBD 1. Tebé C, Espallargues M, Pons JMV, Cancio JM, are currently underway, to evaluate the repre- Clèries M, Inzitari M et al. La fractura de cuello femoral: sentativeness of the sample obtained through evaluación del proceso de atención hospitalario. [Internet]. the RNFC. Barcelona: Ministerio de Sanidad, Servicios Sociales e Igualdad. Agència de Qualitat i Avaluació Sanitàries Perhaps the greatest obstacle to the RNFC’s de Catalunya. 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