Subsequent fracture in nursing home residents with a hip fracture: a competing risks approach

Abstract

Objectives: To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death.

Design: Dynamic cohort study.

Setting: Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts.

Participants: Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site.

Measurements: Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture.

Results: The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture.

Conclusion: Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.

Figure 1

Cumulative incidence of subsequent fracture and death in nursing home residents after a hip fracture. The incidence of subsequent fracture accounts for the occurrence of death as a competing risk using a Cumulative Incidence Competing Risk (CICR) curve. The incidence of death also accounts for the occurrence of subsequent fracture using a CICR curve.