Selective serotonin reuptake inhibitor use and mortality, postoperative complications, and quality of care in hip fracture patients: a Danish nationwide cohort study

Clinical Epidemiology, Aug 2018

Selective serotonin reuptake inhibitor use and mortality, postoperative complications, and quality of care in hip fracture patients: a Danish nationwide cohort study Stine Bakkensen Bruun,1 Irene Petersen,1,2 Nickolaj Risbo Kristensen,1 Deirdre Cronin-Fenton,1 Alma Becic Pedersen1 1Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; 2Department of Primary Care and Population Health, University College London, London, UK Purpose: To examine the association between selective serotonin reuptake inhibitor (SSRI) use and mortality, postoperative complications, and quality of in-hospital care in hip fracture patients. Patients and methods: The study was a nationwide cohort study based on individual-level linked, prospectively collected data from Danish population-based national registries covering all hospitals in Denmark. The health care system in Denmark is tax-funded, and all citizens have equal access to health care services. We included patients with first-time hospitalization due to hip fracture undergoing surgery from 2006–2016. We estimated the risk of 30-day mortality, any unplanned readmission, any reoperation, specific postoperative complications including cardiovascular events and major bleeding, and quality of in-hospital care using Cox and Poisson regression analyses comparing current and former SSRI users with non-users. Results: In 68,487 hip fracture patients, 13,272 (19%) were current SSRI users, 2,777 (4%) were former SSRI users, and 52,438 (77%) were SSRI non-users. The 30-day mortality risk was 13% in current SSRI users (HR 1.16, 1.10–1.21) and 12% in former (HR 1.15, 1.04–1.27) compared with 10% in non-users. The HR for any unplanned readmission was 1.11 (1.02–1.20) in current and 1.13 (1.01–1.27) in former SSRI users and for any reoperation 1.21 (1.11–1.31) in current and 1.04 (0.84–1.28) in former SSRI users compared with non-users. The risk of venous thromboembolism, myocardial infarction, stroke, and bleeding were similar irrespective of SSRI use. No association between current and former SSRI use and quality of in-hospital care was found. Conclusion: In patients undergoing hip fracture surgery, 30-day mortality and overall readmission risk were elevated in both current and former SSRI users compared with non-users. Those currently using SSRI had a 26% increased reoperation risk compared with non-users. However, SSRI use was not associated with increased risk of other postoperative complications and lower quality of in-hospital care. A limitation of this study was the inability to control for potential confounding of social deprivation. Keywords: cohort studies, hip fracture, mortality, postoperative complications, quality of care, selective serotonin reuptake inhibitors

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Selective serotonin reuptake inhibitor use and mortality, postoperative complications, and quality of care in hip fracture patients: a Danish nationwide cohort study

Authors Bruun SB, Petersen I, Kristensen NR, Cronin-Fenton D, Pedersen AB Received 1 March 2018 Accepted for publication 27 May 2018 Published 27 August 2018 Volume 2018:10 Pages 1053—1071 DOI https://doi.org/10.2147/CLEP.S166309 Checked for plagiarism Yes Review by Single-blind Peer reviewers approved by Dr Colin Mak Peer reviewer comments 2 Editor who approved publication: Dr Eric I. Benchimol Stine Bakkensen Bruun,1 Irene Petersen,1,2 Nickolaj Risbo Kristensen,1 Deirdre Cronin-Fenton,1 Alma Becic Pedersen1 1Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; 2Department of Primary Care and Population Health, University College London, London, UK Purpose: To examine the association between selective serotonin reuptake inhibitor (SSRI) use and mortality, postoperative complications, and quality of in-hospital care in hip fracture patients. Patients and methods: The study was a nationwide cohort study based on individual-level linked, prospectively collected data from Danish population-based national registries covering all hospitals in Denmark. The health care system in Denmark is tax-funded, and all citizens have equal access to health care services. We included patients with first-time hospitalization due to hip fracture undergoing surgery from 2006–2016. We estimated the risk of 30-day mortality, any unplanned readmission, any reoperation, specific postoperative complications including cardiovascular events and major bleeding, and quality of in-hospital care using Cox and Poisson regression analyses comparing current and former SSRI users with non-users. Results: In 68,487 hip fracture patients, 13,272 (19%) were current SSRI users, 2,777 (4%) were former SSRI users, and 52,438 (77%) were SSRI non-users. The 30-day mortality risk was 13% in current SSRI users (HR 1.16, 1.10–1.21) and 12% in former (HR 1.15, 1.04–1.27) compared with 10% in non-users. The HR for any unplanned readmission was 1.11 (1.02–1.20) in current and 1.13 (1.01–1.27) in former SSRI users and for any reoperation 1.21 (1.11–1.31) in current and 1.04 (0.84–1.28) in former SSRI users compared with non-users. The risk of venous thromboembolism, myocardial infarction, stroke, and bleeding were similar irrespective of SSRI use. No association between current and former SSRI use and quality of in-hospital care was found. Conclusion: In patients undergoing hip fracture surgery, 30-day mortality and overall readmission risk were elevated in both current and former SSRI users compared with non-users. Those currently using SSRI had a 26% increased reoperation risk compared with non-users. However, SSRI use was not associated with increased risk of other postoperative complications and lower quality of in-hospital care. A limitation of this study was the inability to control for potential confounding of social deprivation. Keywords: cohort studies, hip fracture, mortality, postoperative complications, quality of care, selective serotonin reuptake inhibitors Introduction Hip fracture is a frequent surgical procedure among the elderly.1 It correlates with high medical costs and health care utilization2 and confers increased risk of mortality.3 Thirty-day mortality in elderly surgically treated hip fracture patients is 10% and increases to 30% within 1 year.4 Patients who receive the recommended pre- and postoperative in-hospital care such as pain assessment, nutritional risk assessment, osteoporosis prophylaxis, and basic mobility assessment at admission and discharge may have a lower mortality risk compared with those who do not.5 Additionally, high mortality is linked to the occurrence of postoperative complications, which affect ~20% of elderly hip fracture patients.5,6 The most common postoperative complication is infection.4 However, patients can experience venous thromboembolism (VTE), myocardial infarction (MI), stroke, and gastrointestinal bleeding as well.4,7 Elderly hip fracture patients are often multimorbid and receive multiple prescription medications including selective serotonin reuptake inhibitors (SSRIs).8 SSRIs are prescribed to 10% of Danish elderly aged 65 years or older.9 The most common indications for SSRI prescribing are depression and anxiety.10 In general, SSRI use appears to increase the risk of mortality, new cardiovascular events, and postoperative bleeding.6,11 Previous studies among patients undergoing major surgery, including orthopedic surgeries, reported higher risk of mortality, readmission, and blood transfusion in those using SSRIs perioperatively.12,13 However, a study including orthopedic patients showed no evidence that SSRI use increased the risk of receiving a blood transfusion.14 Thus, existing literature examining the effect of SSRI use on surgery outcome is somewhat inconclusive. The impact of preadmission SSRI use on mortality, postoperative complications, and quality of in-hospital care among (...truncated)


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Stine Bakkensen Bruun, Irene Petersen, Nickolaj Risbo Kristensen, Deirdre Cronin-Fenton, Alma Becic Pedersen. Selective serotonin reuptake inhibitor use and mortality, postoperative complications, and quality of care in hip fracture patients: a Danish nationwide cohort study, Clinical Epidemiology, 2018, pp. 1053-1071, DOI: 10.2147/CLEP.S166309