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DIETARY HABITS AND FUNCTIONAL LIMITATION OF OLDER BRAZILIAN ADULTS: EVIDENCE FROM THE BRAZILIAN NATIONAL HEALTH SURVEY (2013)

 

E. Alves Valle1, J. Vaz de Melo Mambrini1, S. Viana Peixoto1,2, D. Carvalho Malta2, C. de Oliveira3, M.F. Lima-Costa1

 

1. Oswaldo Cruz Foundation, René Rachou Research Centre, Belo Horizonte-MG, Brazil; 2. Federal University of Minas Gerais, School of Nursing, Belo Horizonte-MG, Brazil; 3. Department of Epidemiology & Public Health, University College London, London, UK

Corresponding Author: E. Alves Valle, CPQRR/Fiocruz Belo Horizonte, Av. Augusto de Lima, 1715 – Barro Preto, Belo Horizonte – MG, 30190-002, Brazil, +55 31 3349-7700, estevaovalle@gmail.com

J Aging Res Clin Practice 2016;inpress
Published online August 25, 2016, http://dx.doi.org/10.14283/jarcp.2016.112

 


Abstract

Abstract: Objective: To compare the consumption of selected healthy and unhealthy food groups among elderly Brazilians with daily living activity limitations relative to those with no limitations. Design: Cross-sectional analyses of a nationally representative survey. Setting: The Brazilian National Health Survey, conducted in 2013. Subjects: 11,177 Brazilians aged 60 and over. Results: The prevalence of daily living limitations was 29% (95% CI 27.6,30.5). The consumption of daily meat, beans on a regular basis, and recommended fruit and vegetables intake were 67.1% (95% CI 66.5,68.7), 71.3% (95% CI 69.9,72.8) and 37.3% (95% CI 35.6,39.9), respectively. Compared to those without functional limitation, the consumption of these three food groups was significantly lower among those older adults with functional limitation (Prevalence Ratio = 0.89, 95% CI 0.80,0.98; 0.90, 95% CI 0.82,0.99 and PR 0.86, 95% CI, 0.76,0.96, respectively), independently of age, sex, marital status, living arrangements and education. Level of education showed a strong positive association with fruit and vegetable consumption, and a negative association with bean consumption, a staple diet in Brazil. Conclusions: Our findings highlight the need for public health policies to increase consumption healthy food consumption among those older adults with functional limitations, especially fruit and vegetable intake among those who have low education levels.

Key words: Older adults, nutrition, activity of daily living, disability, healthy ageing, national health survey, Brazil.


 

Introduction

Nutrition among older adults is a significant public health issue in middle income countries overwhelmed with the rapid demographic ageing (1-3). Furthermore, this scenario generates great concern among policy makers because of the burden of disability in old age. There is evidence that a diet rich in vegetables, fruit, fish, nuts and wine is associated with more disability free days, compared to a diet rich in fast food, fried foods, sweets and fizzy drinks (2). A healthy diet is also associated with better cognition and mental health (3). However, physical, mental and financial barriers experienced by people with disabilities may limit their access to a healthier diet (4). A recent study, based on a nationally representative sample of US adults, showed that people with disabilities are less likely to meet recommended levels of saturated fat, fiber, vitamins A and C, calcium and potassium intakes compared to those without disability (4). These findings highlight the need for further research to investigate the association between poorer diet and disability in different countries and cultures.
Brazil has the world’s fifth largest population and has experienced considerable economic growth over the last decades. As a rapidly ageing middle-income country, social policy development for the elderly is of paramount importance (5, 6). From a nutritional perspective, the prevalence of obesity among Brazilians has increased, while the prevalence of undernutrition has an impressive decline (6). Recently, the Ministry of Health developed a guideline to promote healthy diet, as part of the national strategy for the control of non-communicable diseases and associated risk factors (7). As part of the public national health system (in Portuguese, “Sistema Único de Saúde”), Brazil has a national policy for the elderly, which considers the importance of individual functional status (5).  No previous study has compared nutritional patterns between Brazilians with and without disabilities, an essential issue to guide health policies for the elderly.
In the present study, we used data from the most recent Brazilian National Health Survey (8) to describe the dietary habits of older Brazilians, to compare the consumption of selected healthy and unhealthy food groups between those with and without functional limitations and, finally, to identify sociodemographic factors associated to a lower consumption of certain food groups among those individuals with functional limitations.

 

Methods

The Brazilian National Health Survey (PNS)

Data are derived from the National Health Survey (“Pesquisa Nacional de Saúde”) (8), a nationally representative household survey conducted by the Brazilian Institute of Geography and Statistics (IBGE) and Ministry of Health in 2013. The survey employs a complex sampling design. The primary sampling units are census tracts based on the 2010 census and randomly selected from the IBGE national master sampling plan. Within each census tract, households were randomly selected. Within selected households, a randomly selected respondent aged 18 or over was invited to take part in the study. The final sample size of persons aged 18 years and over was 62,986 (8). All survey participants aged 60 years and older were selected for this analysis.

Functional limitation

Physical functioning limitation was defined as reporting having any difficulty in one or more of the following ten basic (ADL) and/or instrumental activities of daily living (IADL): dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, going outside the house using a transportation, managing medications, shopping and managing finances.

Dietary habits

Dietary pattern was assessed by daily or weekly frequency consumption of certain healthy and unhealthy food groups. The following groups, with definitions used, were: regular fish intake (in one or more days per week); regular intake of beans (five or more days per week); recommended fruit and vegetable intake (five or more daily portions, five or more days per week, including wholesome food, in salads or juices); red meat or chicken with visible fat (once or more times per week); full fat milk (any weekly frequency); regular consumption of sweets (five or more days a week); regular ingestion of fizzy drinks or artificial juices (five or more days a week) and high levels of salt (according respondent’s self-perception).In addition, the daily meat consumption (beef, pork and/or chicken) was measured since it is an important marker of protein intake in older adults (9).

Sociodemographic characteristics

Sociodemographic characteristics include age group (60-64, 65-74, 75 and older), sex, marital status (married, divorced/single and widow), number of residents within the household (live alone, two, three or more) and educational attainment. Educational attainment was categorized into: less than four years of schooling, five to eight years of schooling, nine to eleven years of schooling, and 12 years or more.

Statistical analysis

Descriptive analyses were based on prevalence and their respective 95% confidence intervals. In the unadjusted analyses, Pearson Chi Squared test was used to assess the significance of differences between the sociodemographic variables and the dietary patterns of older adults with and without functional limitations. Multivariate analyses, investigating the association between dietary patterns and functional limitations, were performed using prevalence ratios and their 95% confidence intervals through Poisson regression models (10). This was also the statistical approach used to examine the associations between sociodemographic characteristics and daily meat intake, recommended daily intake of fruit and vegetables and regular ingestion of beans of older adults with and without functional limitations. The estimated prevalence ratios from the Poisson regression models were adjusted simultaneously by age, sex, educational attainment, marital status and number of residents within the household. All analyses were performed using Stata version 13.0 and results incorporate appropriate procedures to control for weights and the complex PNS sample design (11).

Ethical approval

The National Health Survey was approved by the National Commission of Ethics in Research on Human Beings (in Portuguese, “Comissão Nacional de Ética em Pesquisa”), of the Ministry of Health, (Process number 328.159 of June 2013). All participants signed a consent form.

 

Results

The present analysis was based on 11,177 survey participants aged 60 years and over. 3,340 (29.0%; 95% CI: 27.6-30.5%) reported some functional limitation. Table 1 presents descriptive statistics for the sample. Overall, participants predominantly aged between 65 and 74, were female, married, residents in households with 3 or more residents and had five to eight years of schooling. The prevalence of women with functional limitation was significantly higher compared to those without functional limitations (62.4% versus 53.9%). Statistically significant differences (p<0.05) between those with functional limitation compared to those without were observed for oldest age (46.5% vs. 16.7%aged 75 and older, respectively), widowed (39% vs 21.5%) and those with educational attainment less than four years of schooling (47.7% vs 25.7%).

Table 1 Sociodemographic characteristics of the sample of older Brazilians, and by functional limitation status (The Brazilian National Health Survey, 2013)

Table 1
Sociodemographic characteristics of the sample of older Brazilians, and by functional limitation status (The Brazilian National Health Survey, 2013)

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances; %: (95% CI): weighted prevalence and 95% confidence interval; * To test differences between those with and without functional limitation (Pearson Chi-squared test)

 

The prevalence of selected food groups intake among study participants, and by functional limitation, is displayed in Table 2. Overall, higher prevalence rates were found for weekly consumption of full fat milk (73.8%), regular intake of beans (71.3%), daily consumption of meat (67.1%) and regular fish intake (58.4%). On the other hand, lower prevalence rates were observed for the recommended intake of fruit and vegetables (37.3%), weekly intake red meat or chicken with visible excess of fat (28.2%), regular sweets (17.2%), regular fizzy drinks/artificial juices (12.0%) and high salt intake (7.9%). Significant associations (p<0.05) with functional limitation were found with daily meat consumption (64.1 vs 68.4%, those with and without limitations, respectively), regular fish intake (53.3% and 60.4%, respectively), recommended amount of fruit and vegetable intake (32.1% vs 39.4%, respectively) and excessive salt intake (6.3% vs 8.6%, respectively).

Table 2 Dietary habits of older Brazilians, and by functional limitation status (The Brazilian National Health Survey, 2013

Table 2
Dietary habits of older Brazilians, and by functional limitation status (The Brazilian National Health Survey, 2013

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances; %: (95% CI): weighted prevalence and 95% confidence interval; * To test differences between those with and without functional limitation (Pearson Chi-squared test)

 

Table 3 presents results of multivariate Poisson regression models for each outcome. After adjusting for sociodemographic characteristics, the dietary patterns that remained significantly associated with functional limitation were: daily meat intake (PR = 0.89, 95% CI: 0.80-0.98), recommended fruit and vegetables intake (PR = 0.86, 95% CI: 0.76-0.96) and regular bean consumption (PR = 0.90, 95% CI: 0.82-0.99).

Table 3 Multivariate analysis of dietary habits and functional limitation among older Brazilians (Brazilian National Health Survey, 2013)

Table 3
Multivariate analysis of dietary habits and functional limitation among older Brazilians (Brazilian National Health Survey, 2013)

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances; PR (95% CI): weighted prevalence ratios and their 95% confidence intervals estimated by Poisson regression models and adjusted for age, sex, marital status, household number of residents and educational attainment; *p < 0.05

 

Results from the multivariate analysis of the association of sociodemographic characteristics with selected dietary habits among those participants with and without functional limitation are shown in table 4.  Generally, the association was similar in both functional groups, as follows: women had a positive association with the recommended fruit and vegetable intake and a negative association with regular bean consumption; the number of residents within the household (i.e. three or more) was positively associated with regular bean consumption; schooling level was positively correlated with recommended vegetable intake, and negatively correlated with regular bens intake. Conjugal status showed no significant association with the consumption of all the above mentioned foods in any group. Oldest aged showed a negative association with regular bean intake among those with functioning limitations.

Table 4 Multivariate analysis of sociodemographic factors, selected dietary habits and functional limitation among older Brazilians (Brazilian National Health Survey, 2013)

Table 4
Multivariate analysis of sociodemographic factors, selected dietary habits and functional limitation among older Brazilians (Brazilian National Health Survey, 2013)

1. At least one difficulty in the following ten activities: dressing, walking across a room, bathing or showering, eating, getting in or out of bed, using the toilet, handling transportation (driving or navigating public transit), managing medications, shopping and managing finances;  *p < 0.05; ** p <= 0.001; PR (95% CI): weighted prevalence ratios and their 95% confidence intervals estimated by Poisson regression models and adjusted for age, sex, marital status, household number of residents and educational attainment

 

Discussion

The key findings from this study, based on a nationally representative sample of non-institutionalised older Brazilian adults, are: (1) those with functional limitations were less likely to a daily intake of meat, recommended intake of fruit and vegetables and regular ingestion of beans, independent of age, sex and other sociodemographic characteristics; (2) educational attainment was the strongest sociodemographic factor associated to recommended fruit and vegetables intake (higher intake among those with higher educational attainment).
Our findings corroborated previous research based on data from the Brazilian National Household Survey (PNAD) conducted in 1998, 2003 and 2008 that showed higher prevalence of functional limitation among the oldest old, women and those with a low level of education (12,13). Regarding dietary patterns, our study found similar results to earlier descriptive analyses from the Brazilian National Health Survey (2013), based on data from the population aged 18 and older, showing high consumption of healthy foods (such as beans and fish), in contrast with low consumption of fruit vegetables and high intake of food rich in saturated fat (non-lean red meat, chicken or full fat milk) (14, 15).
After adjusting for sociodemographic factors, the dietary patterns of older Brazilians with and without functional limitations were similar, regarding the regular consumption of fish, food rich in fat, fizzy drinks or artificial juices, sweets and salt. On the other hand, the daily meat intake (red meat, chicken and/or fish) was smaller among those with functional limitation. To note that low protein intake may lead to an increased risk to sarcopenia, frailty, falls and fractures resulting into an even greater risk to develop functional limitations (9, 16). Brazilian guidelines (7) and others (17, 18) recommend a diet rich in fruit, vegetables and pulses, like beans, for its important preventive role against the development of non-communicable diseases (17, 18). The current analysis shows that older adults with functional limitations are 10% and 14% less likely to eat regularly beans and the recommended intake of vegetables, respectively.
It is worth mentioning that there are physical, mental and financial barriers which could prevent older adults with functional limitation to have a healthier diet (4). Unfortunately, data from national health surveys usually do not generate information that allows us to identify these barriers. Therefore, the present analysis was focused on sociodemographic factors associated to some healthy diet habits. Overall, the sociodemographic factors associated to daily intake of meat, recommended intake of fruit and vegetables and regular ingestion of beans were similar among those participants with and without functional limitations. Compared to men, women with and without functional limitation reported less meat and beans intake and higher fruit and vegetable consumption. Similar findings regarding women eating more fruit and vegetables were found in Canada (19) but not in South Africa and Iran (20, 21). Furthermore, a qualitative study showed that Canadian women were more aware of the benefits of such food group compared to men (22). Regular ingestion of beans also had a positive and independent association with household number of residents.
As previously mentioned, educational attainment was the strongest sociodemographic factor associated to fruit and vegetable and intake among both those with and without functional limitation. The prevalence of recommended fruit and vegetable intake increased by each level of educational attainment in both functioning groups (with and without functional limitation), with those with 12 or more years of schooling having the highest intake levels. Older Brazilian adults with and without functional limitations with 12 or more years of schooling degree were 207% and 258% more likely to regularly eat fruits and vegetables compared to those with low educational attainment. The positive association between the recommended fruit and vegetables intake and education or income has also been observed in other countries (19, 21, 23). An interesting study conducted in Brazil using data from the Brazilian National Family Budget Survey showed that the total household expenditure on fruit and vegetables is inversely proportional to the price of such food and directly proportional to the household income (24).
In contrast, regular consumption of beans, an important ingredient of the Brazilian staple diet, decreased gradually according to level education in both those with and without functional limitation. Older adults with and without functional limitation with 12 or more years of schooling were17% and 29%, respectively, less likely to eat beans regularly than those with lower education level. A negative association between educational level and beans intake among adults residing in large cities in Brazil has been previously reported (25,26). Beans are an important source of protein, fibre, minerals, vitamins and flavonoids with potential benefits to health (27). This type of food has been considered by some authors as the “meat of the poor” due to its important nutritional value in low income countries (28) and perhaps it has been replaced by other types of food culturally considered “posh” by higher socioeconomic groups’ individuals.
This study has some strengths and limitations. The strength of the present study lies in its large nationally representative sample of older Brazilian with data on functional limitation and dietary habits. Therefore, to the best of our knowledge, this is the first study to compare dietary habits of older Brazilian with and without functional limitations. However, because the data are cross-sectional, we are unable to determine causal relationships and directionality of the observed associations. We are not able to establish if dietary habits were adopted before the development of functional limitation or vice-versa. In addition, the dietary habits module of the interview is rather concise and like any questionnaire on diet is prone to recall bias, leading to under or overestimation of amount of consumption (29).  However, it is unlikely that differential associations have affected those with and without functional limitations. Finally, in our analyses we could not establish an individual and/or household income which could directly affect the food choice purchase (24). This limitation was partially addressed by using data on educational attainment which is an important socioeconomic position indicator.
In 2006, the Brazilian Ministry of Health implemented the National Health Policy for the Elderly raising the issue of how important it is to include functional limitation as one of its policies (5).  27 million Brazilian people are currently aged 60 and older (30). Taking into account the findings from the present study, about 5.4 million older adults in Brazil eat less than the recommended amount of fruit and vegetables as indicated by the WHO (31). In conclusion, our findings highlight the importance of assessing dietary habits when investigating functional limitation in older adults. Our findings also highlight the need for public health policies to increase consumption healthy food consumption among those older adults with functional limitations, especially fruit and vegetable intake among those who have low education levels.

 

Acknowledgements: This study was funded by the Brazilian Ministry of Health, Secretariat of Health Surveillance. MFLC and SVP are fellowship researchers of the Brazilian National Council for Scientific and Technological Development (CNPq).

 

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HIP FRACTURE IN A DEVELOPING COUNTRY: A PICTURE IN NEED OF CHANGE

 E.I.O. Vidal1, D.C. Moreira-Filho2, R.S. Pinheiro3, R.C. Souza4, L.M. Almeida5, K.R. Camargo Jr6, P.J.F. Villas Boas1, F.B. Fukushima7, C.M. Coeli3

 

1. Geriatrics Division – Internal Medicine Department – Universidade Estadual Paulista (UNESP); 2. Preventive and Social Medicine Department – Universidade Estadual de Campinas (UNICAMP); 3. Instituto de Estudos em Saúde Coletiva (IESC) – Universidade Federal do Rio de Janeiro (UFRJ); 4. Faculdade de Ciencias Medicas – Universidade Estadual do Rio de Janeiro (UERJ); 5. Epidemiology Division – Instituto Nacional do Câncer (INCA); 6. Social Medicine Institute – Universidade Estadual do Rio de Janeiro (UERJ); 7. Anesthesiology Department – Universidade Estadual Paulista (UNESP)

Corresponding Author: Edison Iglesias de Oliveira Vidal, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu – UNESP, 18618-970 , Botucatu – SP – Brazil, E-mail: eiovidal@fmb.unesp.br

 


Abstract

Objectives: To describe the clinical profile, patterns of care and mortality rates of aged patients who have undergone hip fracture surgical repair. Design: Retrospective patient record study. Setting: A public university hospital in Rio de Janeiro, Brazil. Participants: 352 patients aged 60 and older who underwent surgery for hip fracture between 1995-2000. Measurements: Sociodemographic data, type of fracture, cause of fracture, time from fracture to surgery, physical status, Charlson comorbidity index, type of surgery and anesthesia, access to in-hospital physiotherapy, use of antibiotic and thromboembolism prophylaxis, and mortality within one year after hospital admission. Results: Among 352 subjects, 74.4% were women. The mean age overall was 77.3 years. Very long delays from the time of fracture to hospital admission (mean 3 days) and from hospital admission to surgery (mean 13 days) were observed. Most femoral neck fractures (82.7%) were managed by hip arthroplasties, while 92.8% of the intertrochanteric fractures underwent internal fixation procedures. Less than 10% of patients received in-hospital physiotherapy. Mortality rates 30 days, 90 days and one year after hospital admission were 3.4%, 8.0% and 13.4%, respectively. Conclusion: Our study provides evidence within the context of a developing country of major gaps in the quality of care of vulnerable older adults who suffered a hip fracture. Our findings suggest that hip fracture has not been treated as an urgent condition or a priority within the Brazilian public healthcare system. Further research should address current patterns of care for hip fracture in Brazil and in other developing countries.

 

Key words: Hip fractures, osteoporosis, quality of health care, developing countries, Brazil.


 

Introduction

Hip fracture represents the most severe consequence of osteoporosis and a major cause of morbidity, institutionalization and mortality for older adults worldwide (1–4). Around the Globe there is great variability concerning the incidence of hip fracture and its related mortality (5–8). Even though the greatest increase in the incidence of hip fracture is expected to occur in the developing countries of the world, those are also the regions from where less information is available on the epidemiology of those fractures (6, 8). There is particularly few data concerning Latin American older adults with hip fracture (8–11). More data on the epidemiology of those fractures is fundamental for the design of age-friendly public policies in those countries, where population aging is a relatively new phenomenon. Therefore, we conducted a study to describe the clinical profile, the patterns of care, and mortality rates of individuals aged 60 and older who underwent surgical repair of a hip fracture at a public university hospital in the city of Rio de Janeiro, Brazil.

 

Methods

The medical records of all patients aged 60 years and older admitted with a primary diagnosis of hip fracture (first three digits of International Classification of Diseases, 9th revision, ICD-9, code 820) between January 1st, 1995 and December 31st, 2000 were retrospectively reviewed. Patients with pathological hip fracture related to malignancy or who did not undergo surgical repair were excluded.

Review of medical records was performed using a standardized data abstraction form, which was completed by trained medical students under the supervision of a senior medical researcher (LMA). Before being used for this research the abstraction form was pretested with a sample of medical charts and corrections were implemented in order to facilitate the abstraction process and minimize bias. The medical supervisor reviewed all data for inconsistencies and medical records were reappraised accordingly. The same professional was responsible for the insertion of all data into the database.

To assess mortality rates within one year after hospital admission, records were linked to the database of the Brazilian Mortality Information System from January 1st, 1995 to December 31st, 2001 using Probabilistic Record Linkage Methodology (9, 12–16). Previous research in a similar setting revealed 85.5% sensitivity, 99.4% specificity, 98.1% positive predictive value and 94.9% negative predictive value for correct matching of records between databases using this methodology (17). RecLink II Software (18) was used to implement the Probabilistic Record Linkage Methodology followed by manual examination of pairs of records with higher probability of representing a true match between databases.

Frequency tables were created for the following variables: sex, age, income strata, marital status, living arrangements, type of hip fracture, type of injury leading to the fracture, type of surgical treatment and anesthesia, prophylaxis against venous thromboembolism and surgical infections (i.e. prophylactic antibiotic regimens), access to in-hospital physiotherapy care, comorbidities as ascertained by the Charlson comorbidity index (19), and American Society of Anesthesiology (ASA) physical status score. Statistical analyses were restricted to the presentation of simple frequencies and the calculation of 95% confidence intervals according to standard methods (20). The R software (version 2.10.1) was used for such purposes (21).

The present research was approved by the ethics committee of the Public Health Studies Institute of the Universidade Federal do Rio de Janeiro. Because of the retrospective nature of the study involving patients’ medical records and anonymous treatment of data, the ethics committee waived the requirement for informed consent.

 

Results

Figure 1 shows the flow diagram of the inclusion of patients in the study. Among the 352 patients fulfilling the proposed inclusion criteria, there were 262 (74.4%) women. The mean age overall was 77.3 years and women were mean 3.7 years older than men (mean ages 78.2 and 74.5 years, respectively; P = 0.001). The mean and median lengths of hospital stay were 21 and 17 days, respectively, with an interquartile range of 14 to 24 days. The mean and median times from the occurrence of hip fracture to hospital admission were 3 and 1 days, respectively, with an interquartile range of 0 to 4 days. The mean and median times from hospital admission to surgery were 13 and 11 days, respectively, with an interquartile range of 8 to 17 days. Figure 2 shows the distribution of time from hospital admission to surgery. Table 1 depicts the sociodemographic characteristics of the patients. Table 2 shows the clinical profile of patients including number of comorbidities, types and causes of hip fracture, Charlson comorbidity index and ASA physical status score. Table 3 displays the frequencies of surgical and anesthetic approaches adopted, as well as the frequencies of in- hospital physiotherapy, antibiotic and thromboembolism prophylaxis. Most femoral neck fractures (82.7%) were managed by hip arthroplasties, while 92.8% of the intertrochanteric fractures and 96.2% of the subtrochanteric fractures underwent internal fixation procedures. In-hospital mortality was 5.4%. Mortality rates 30 days, 90 days and one year after hospital admission were 3.4%, 8.0% and 13.4%, respectively.

 

Figure 1: Flow diagram of inclusion of patients in the study.

 

Table 1: Sociodemographic characteristics of patients.

 

Figure 2: Histogram of the interval of time* from hospital admission to surgery for 352 patients who underwent surgical repair of a hip fracture between 1995-2000.

 

Discussion

Probably, the most striking finding of the current research was the occurrence of mean intervals of time from fracture to hospital admission and thereafter to surgery of 3 and 13 days, respectively. Those intervals of time from fracture to surgery are remarkably different from those reported in developed countries, where the vast majority of patients undergo surgery within the first 48h of hospital admission (22–27). Even though there is still some degree of debate over the association between surgical timing and patient mortality after a hip fracture (25, 28, 29), there is wide consensus in the literature that hip fracture patients should be operated on as early as possible after hospital admission, provided there are no conditions that can be corrected or improved prior to surgery, since long waiting times for surgery are associated with pain, pressure ulcers, long hospital stays, distress, and delayed mobilization (23, 25, 27–30). We have recently shown for the same context of care that those long delays from fracture to hospital admission are associated with increased mortality risk (31).

Less than 10% of patients received in-hospital physiotherapy care, which is significantly divergent from current recommendations for early mobilization for most patients following the surgical repair of a hip fracture (32, 33). Such a low frequency of in-hospital physiotherapy care also mirrors important limitations in the access to optimal healthcare resources by older adults, since functional recovery after hip fracture is highly dependent on early rehabilitation after surgery (34). Nevertheless, almost 95% of patients received thromboembolism and antibiotic prophylaxis, which are significantly easier interventions to implement within any institution than the organization of post-surgical rehabilitation resources.

The current observations of long delays to hospital admission and to surgery above the standard of care in developed countries (i.e. surgery within 48h of hospital admission), and the remarkably low frequency of in- hospital physiotherapy care indicate that, even though hip fracture is associated with lower survival rates than that of most invasive cancers pooled together (35), it has not been treated as an urgent condition or a public health priority in Brazil. Because there is evidence that injuries and surgical conditions represent a problematic and neglected aspect of healthcare in developing countries we believe that similar and even worse patterns of care are likely in other developing regions of the World (36–40). This perspective is alarming since those fractures represent an enormous burden for society and because the greatest increase in the incidence of hip fracture is predicted to take place in the developing countries of the world (6, 8).

We hypothesize that those findings might reflect a picture of ageism within the Brazilian healthcare system (41, 42), where older adults have less access to more costly procedures within the public healthcare system than younger individuals, as has been shown by others (43). We hypothesize several other reasons that could explain the findings of delayed surgical timing and low physiotherapy frequency within our study. First, surgical procedures for hip fracture may have been scheduled as elective instead of urgent procedures, and therefore occurred according to operating theater availability, without prioritizing those vulnerable patients. Second, it is possible that in Brazil the lay public and even many healthcare professionals are frequently unaware of the often life-threatening meaning of a hip fracture for older people. Those hypotheses warrant further investigation by future studies. Although universal access to public health care in Brazil has been legally established since 1988, patients still often suffer from suboptimal care in several areas of healthcare provision (44). While the population is aging rapidly, the public healthcare system is still struggling to recognize and adapt to the needs of older people (45).

High rates of arthroplasty procedures for femoral neck fractures were observed. This finding is probably related to the large intervals of time from fracture to surgery, since those delays are associated with increased risk of fracture displacement and avascular necrosis of the head of the femur, and therefore represent a clear indication for hip arthroplasty (46).

The majority of patients (74.1%) underwent neuroaxial anesthesia (i.e. spinal or epidural), which represents a somewhat different pattern than that observed in many other regions of the Globe where general anesthesia usually represents a larger share of the anesthetic procedures performed for hip fracture patients (47–49). The debate over what type of anesthetic procedure is best suited for hip fracture patients does not seem to be resolved. Notwithstanding, recent systematic reviews disclosed lower mortality 30 days after surgery, lower incidence of deep venous thrombosis and lower rates of postoperative mental confusion for hip fracture patients who underwent neuroaxial anesthesia than for those submitted to general anesthesia (49, 50).

The one-year mortality rate observed (13.4%) was much lower than the 21.5% mortality rate described previously in a study encompassing all public hospitals in the city of Rio de Janeiro (9) and lies in the lower limits of mortality reported for hip fracture around the world (1, 2). The finding of low patient mortality concomitant to markers of suboptimal patient care discussed in the previous paragraphs may seem paradoxical at first. However, this apparent paradox can be explained by several factors, as follows. First, University hospitals have been shown to be associated with lower mortality rates for hip fracture than general hospitals, even though they often display longer intervals of time from hospital admission to surgery than community hospitals (24). Second and most important, selection bias must be strongly considered as a reason for the discrepancy between inadequate patterns of care and low mortality rates. Frailer and sicker patients, who had been admitted with a hip fracture to a community hospital without hip fracture surgical capability, were likely not considered fit to be transferred to the university hospital under study or died before they could be transferred, hence creating selection bias. Two observations are consistent with this last hypothesis: (a) most patients in this study were attributed a low Charlson comorbidity index and only roughly one third of patients were considered to have a severe systemic disease as ascertained by the ASA physical status classification; (b) the patient population was relatively younger than usually reported by most studies from developed countries (24, 51, 52).

At least 49.4% of patients in our study belonged to a low socioeconomic stratum. About 60% of patients were widowed, divorced or single. As usual in epidemiological studies about hip fracture among older adults, most patients (74.4%) were women. Even though the relationship between socioeconomic status and risk of falls is debated (53), there is evidence that lower socioeconomic status is associated not only with increased incidence of hip fracture (54–57) but also with increased mortality after fracture (58). Divorced, widowed and unmarried status have also been reported by others to be associated with increased risk of hip fracture (56, 59). The association between low socioeconomic status and increased risk of hip fracture may be related to several factors ranging from decreased bone mineral density and underlying health behaviors to environmental influences (55).

Several limitations of this study must be considered. Since its design was based on the retrospective abstraction of medical records, we had limited or no access to some data on important aspects of patients’ baseline characteristics and outcomes, such as socioeconomic status and functional outcomes. Second, review of medical records is often associated with error and bias, which can never be completely discarded in studies like ours. Nevertheless, most of the data that we collected for this analysis was relatively straightforward (e.g. date of hospital admission, date of surgery and record of occurrence of in-hospital physiotherapy care) and an experienced medical supervisor worked in close contact with the chart reviewers in order to attempt to minimize bias. In addition, other researchers have conducted valuable studies about the epidemiology of hip fractures using similar methods (60, 61). Third, limitations in methodology mean that the present results are not generalizable to the whole city of Rio de Janeiro or to other regions of the country. It is nevertheless reasonable to presume that the current findings have significant similarities to the patterns of care in other public hospitals in the same region, which are part of the same public healthcare system. Fourth, our results are at least 10 years old and a note of caution should be added to their generalizability to current practice. However, more recent studies about hip fracture among older adults from other regions of Brazil also showed long surgical delays, which suggests that the substandard patterns of care we have reported might still be common and may require urgent public health attention (62, 63).

 

Conclusions

Our study provides evidence within the context of a developing country of major gaps in the quality of care of vulnerable older adults who sustained a hip fracture between 1995 and 2000. Those findings suggest that hip fracture has not been treated as an urgent condition or a priority within the Brazilian public healthcare system. Further research should address the current patterns of care for hip fracture in the elderly both in Brazil and in other developing countries. Since our findings have been at least in part replicated by more recent studies conducted in other regions of our country, we believe that urgent public health attention is warranted towards the care of older adults sustaining a hip fracture in Brazil.

 

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