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Patient and system factors of mortality after hip fracture: a scoping review Sheehan, K. J; Sobolev, B.; Chudyk, A.; Stephens, T.; Guy, P. Apr 14, 2016

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RESEARCH ARTICLE Open AccessPatient and system factors of mortalityafter hip fracture: a scoping reviewK. J. Sheehan1*, B. Sobolev1, A. Chudyk2, T. Stephens1 and P. Guy2,3AbstractBackground: Several patient and health system factors were associated with the risk of death among patients withhip fracture. However, without knowledge of underlying mechanisms interventions to improve survival post hipfracture can only be designed on the basis of the found statistical associations.Methods: We used the framework developed by Arksey and O’Malley and Levac et al. for synthesis of factors andmechanisms of mortality post low energy hip fracture in adults over the age of 50 years, published in English,between September 1, 2009 and October 1, 2014 and indexed in MEDLINE. Proposed mechanisms for reportedassociations were extracted from the discussion sections.Results: We synthesized the evidence from 56 articles that reported on 35 patient and 9 system factors of mortalitypost hip fracture. For 21 factors we found proposed biological mechanisms for their association with mortalitywhich included complications, comorbidity, cardiorespiratory function, immune function, bone remodeling andglycemic control.Conclusions: The majority of patient and system factors of mortality post hip fracture were reported by only oneor two articles and with no proposed mechanisms for their effects on mortality. Where reported, underlyingmechanisms are often based on a single article and should be confirmed with further study. Therefore, one cannotbe certain whether intervening on such factors may produce expected results.Keywords: Scoping review, Hip fracture, Mortality, Patient factors, System factorsWhat is previously known Excess mortality persists for years post hip fracture. Several patient and system factors have beenassociated with the risk of death in patients with hipfracture. However underlying mechanisms of the foundassociations are rarely discussed.What this study adds We synthesized the evidence from 56 recent articlesthat reported on 35 patient and 9 system factors ofmortality post hip fracture. The majority of factors were reported with noproposed mechanisms for their effects on mortality.Where reported, underlying mechanisms are oftenbased on a single article. The proposed biological mechanisms includecomplications, comorbidity, cardiorespiratoryfunction, immune function, bone remodeling andglycemic control.BackgroundHip fracture is a leading cause of injury related mortalityin older adults [1]. Omsland and colleagues reportedmortality rates five times higher in men and three timeshigher in women compared to the general population inthe first year post fracture [2]. This excess mortality per-sists 10 years post fracture [2, 3].The existing literature identifies patient and systemfactors associated with the risk of death among patientswith hip fracture. However, no attempt has been madeto synthesize this literature on the underlying mecha-nisms for these associations.* Correspondence: sheehakj@mail.ubc.ca1School of Population and Public Health, University of British Columbia,Vancouver, CanadaFull list of author information is available at the end of the article© 2016 Sheehan et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Sheehan et al. BMC Musculoskeletal Disorders  (2016) 17:166 DOI 10.1186/s12891-016-1018-7Without knowledge of mechanisms mediating an as-sociation, interventions to improve survival post hipfracture can only be designed on the basis of the re-ported statistical associations. We believe designinginterventions should rely on knowledge about a modi-fiable factor with negative effect on survival. Wheremodifiable factors lie on the causal pathway betweenexposure and outcome determines the focus of anintervention.Scoping reviews represent an approach to summar-izing the range of evidence on a subject, to clarify acomplex concept, and to help refine subsequent re-search questions for a full systematic review [4, 5].This review contributes to the existing literature bysynthesizing the evidence available on patient and sys-tem factors of mortality after hip fracture. To go be-yond traditional reports, we extract and synthesizeadditional information on biological and hypotheticalmechanisms for reported associations. More specific-ally, the aims of this review are 1) to identify patientand system factors of mortality after hip fracture, and2) collate the description of proposed mechanisms fortheir associations with mortality.MethodsThe key elements of the scoping review framework in-clude formulating the research question, identifying rele-vant studies, selecting studies from electronic database,charting the extracted data and collating, summarizingand reporting findings. We extend this framework bycollecting information on the underlying mechanismsfor found associations. We have followed to a widelyrecognized framework by Arksey and O’Malley [6] andrecommendations of Levac et al. [5] for conducting andreporting scoping reviews. This scoping review synthe-sizes published literature and ethical approval was notrequired.The population of interest is frail adults aged 50 yearsor older admitted to acute care with non-pathologic lowenergy hip fracture. Concepts of interest include bothpatient and system factors. The outcome of interest ismortality following usual care.Study selectionOne reviewer searched MEDLINE using the searchterms “mortality” Medical Subject Headings [MeSH]AND “hip fracture” [MeSH] and screened studies for eli-gibility. Studies were first screened according to title andabstract with those that appeared suitable selected for afull-text review using standardized inclusion criteria(Table 1). Studies marked as ‘maybe for inclusion’ werescreened by a second reviewer for eligibility.We included reports from 2009 or later to minimizethe potential biasing effects of demographic aging [7–9],surgical advancements [10], and changes in delivery ofhip fracture care [11–13]. Intervention-based studieswere excluded as they do not reflect hip fracture mortal-ity following usual care. Studies whose main independ-ent variables were laboratory tests or operation typewere also excluded as they were considered outside ofthe current scope of interest. Finally, only studies whichconducted a regression analysis were included as regres-sion analysis was deemed a proxy for adequate samplesize [14].Using a formal instrument, one reviewer extracted au-thors name, publication date, timing of assessment rela-tive to the hip fracture event, length of follow up,patient and system factors from each article. The signifi-cance of statistical associations between the factors andmortality was derived from the 95 % confidence intervalsreported in the articles. The proposed mechanisms formortality were extracted from discussions by one re-viewer. The accuracy of extraction was assessed by a sec-ond reviewer.Collating, summarizing and reporting resultsPatient and system factors of mortality studied in thereviewed articles are summarized in Tables 2, 3 and 4.Factors with a proposed mechanism of their effects onmortality are summarized in Tables 5 and 6 with indica-tion whether the mechanisms is hypothetical.Table 1 Inclusion criteria for the literature searchTerm IncludeStudy population Men & women ≥50 years of age with non-pathological low energy hip fractureStudy design 0bservational studiesFactors Patient and system factors of mortalityAssociations Estimates from regression analysisOutcome Mortality (in-hospital, 30 day, 12 month, >12 month)Date Between Sep 1, 2009 and Oct 1, 2014Language EnglishGeography WorldwideSheehan et al. BMC Musculoskeletal Disorders  (2016) 17:166 Page 2 of 13Table 2 Articles studying mortality in relation to injury and complicationsFracturetypeInjuryseverityAdditionaltraumaShock Complications CardiovascularcomplicationsDecubitus ulcer GastrointestinalbleedingPulmonarycomplicationsClostridiumdifficileRenalfailurePneumonia DeliriumBelmont 2014 [15] √ √Neuhaus 2013 [17] √ √Miller 2012 [22] √Gold 2012 [24] √Librero 2012 [23] √Tarazona-Santabalbina 2012 [47] √*Lee 2011 [62] √Miyanishi 2010 [63] √Vaseenon 2010 [65] √*Juliebo 2010 [66]Rahme 2010 [55] √ √Lapcevic 2010 [57] √ √Juliebo 2010 [66] √*Berry 2009 [60] √ √Gulihar 2009 [41] √Among all 1 2 1 1 1 1 2 1 1 1 2 1 1*no statistical association foundSheehanetal.BMCMusculoskeletalDisorders (2016) 17:166 Page3of13Table 3 Articles studying mortality in relation to demographic factors and comorbidityAge Sex Race Preadmission residence Functional status Any comorbidity Liver disease Diabetes Malignancy Malnutrition Low Body Mass Index*Belmont 2014 [15] √Neuhaus 2013 [17] √ √ √Williams 2013 [36] √ √ √Hagino 2013 [16] √Talsnes 2013 [37] √Uzoigwe 2013 [19] √ √ √ √Clement 2013 [42] √Daugaard 2012 [18] √ √ √Le-Wendling 2012 [20] √ √ √Librero 2012 [23] √ √ √Huddleston 2012 [44] √Adunsky 2012 [43] √ √Gupta 2012 [45]Valizadeh 2012 [46] √ √**** √ √****Tarazona-Santabalbina 2012 [47] √ √ √ √Pioli 2012 [48] √Sanz-Reig 2012 [49] √ √Vidan 2011 [25] √ √ √Koval 2011 [26] √ √Frost 2011 [27] √ √ √ √Kirkland 2011 [38] √Carretta 2011 [39] √ √ √ √Gulcelik 2011 [52] √Talsnes 2011 [53] √ √ √Baker 2011 [64]LeBlanc 2011 [70] √Holvik 2010 [54] √ √Kesmezacar 2010 [67] √Rahme 2010 [55] √ √ √ √ √ √Forte 2010 [56] √ √ √Lapcevic 2010 [57] √ √ √ √ √Miyanishi 2010 [63] √Juliebo 2010 [66] √ √ √Sheehanetal.BMCMusculoskeletalDisorders (2016) 17:166 Page4of13Table 3 Articles studying mortality in relation to demographic factors and comorbidity (Continued)Jamal 2010 [59] √Bjorgul 2010 [69] √ √ √Pereira 2010 [58] √ √ √ √**** √Vaseenon 2010 [65] √Berry 2009 [60] √ √ √Lefaivre 2009 [33] √ √ √Vidal 2009 [35] √ √ √Feng 2009 [68] √Among all 23 23 2 3 8 23 2 3 2 2 3Sheehanetal.BMCMusculoskeletalDisorders (2016) 17:166 Page5of13Table 3 Articles studying mortality in relation to demographic factors and comorbidity (Continued)Obesity SecondaryHyperparathyroidism**CardiacdiseaseCardiacarrhythmiaCongestiveheart failure***Coronary arterydisease¥Myocardialinfarction§Cerebrovascularaccident¶Anemia CognitiveimpairmentDementiaBelmont 2014 [15] √Neuhaus 2013 [17] √Williams 2013 [36] √Hagino 2013 [16]Talsnes 2013 [37]Uzoigwe 2013 [19]Clement 2013 [42]Daugaard 2012 [18]Le-Wendling 2012 [20]Librero 2012 [23]Huddleston 2012 [44] √ √ √Adunsky 2012 [43] √Gupta 2012 [45] √Valizadeh 2012 [46]Tarazona-Santabalbina2012 [47]√Pioli 2012 [48]Sanz-Reig 2012 [49] √ √Vidan 2011 [25] √Koval 2011 [26]Frost 2011 [27] √Kirkland 2011 [38]Carretta 2011 [39] √ √Gulcelik 2011 [52]Talsnes 2011 [53]Baker 2011 [64] √LeBlanc 2011 [70]Holvik 2010 [54]Kesmezacar 2010 [67]Rahme 2010 [55] √ √ √Forte 2010 [56]Lapcevic 2010 [57] √ √Sheehanetal.BMCMusculoskeletalDisorders (2016) 17:166 Page6of13Table 3 Articles studying mortality in relation to demographic factors and comorbidity (Continued)Miyanishi 2010 [63] √Juliebo 2010 [66] √ √Jamal 2010 [59] √Bjorgul 2010 [69]Pereira 2010 [58] √Vaseenon 2010 [65]Berry 2009 [60] √ √ √Lefaivre 2009 [33]Vidal 2009 [35]Feng 2009 [68]Among all 1 1 1 5 5 3 2 2 1 1 7*Body mass index** Secondary hyperparathyroidism*** Congestive heart failure****no statistical association found¥ Coronary artery disease§ Myocardial infarction¶ Cerebrovascular accidentSheehanetal.BMCMusculoskeletalDisorders (2016) 17:166 Page7of13ResultsSearch resultsThe search produced 241 articles for initial title and ab-stract screening. Figure 1 shows the selection processwhich identified 56 articles used in this review. Amongthe selected articles, 21 reported on in-hospital mortality[15–35], 4 reported on 30 day mortality [36–39], 20 re-ported on 12 months mortality [40–59], and 11 reportedmore than 12 month mortality [60–70].Patient factors of mortalityWe identified 35 patient factors of mortality post hipfracture reported in the reviewed articles, Tables 2 and 3.The majority of factors were studied by only one or twostudies included in this review. There is a general con-sensus in the literature that mortality is associated withage, sex, comorbidity, functional status, dementia,arrhythmia and congestive heart failure. We noted con-flicting reports for the association between mortality andboth fracture type [17, 65] and delirium [47, 62, 66].For 14 factors we found a proposed mechanism of theireffects on mortality, Table 5. Biological mechanisms in-cluded comorbidity [47, 70], cardiorespiratory function[68], immune function [38], bone remodeling [52],glycemic control [52], and calcium homeostasis [32].Non-biological mechanisms included hospitalization delay[50], surgical delay [25, 48] and length of stay [36]. Someproposed included hypothetical mediators, such as re-duced reserve capacity [22, 37], a patent foramen ovale[37] and reduced wound healing [52]. Fig. 2 shows two ex-amples of the mechanisms proposed for patient factors inthe reviewed articles. First, the onset of complications me-diates the effect of cardiorespiratory function on mortality[63]. Second, a hypothetical reduction in reserve capacitymediates the mortality effect of age and extent of comor-bidity [22, 37].System factors of mortalityIn the reviewed articles, we identified 9 system factorsof mortality post hip fracture including hospitalizationdelay, July admission, surgical delay, anaesthetic type,intensive care admission, hospital volume, surgeonvolume, nursing volume and length of stay, Table 4.There is no consensus in the literature on system fac-tors of mortality. The most studied factor was surgi-cal delay (9 articles). However, the association ofmortality with surgical delays is disputed by reportsof no association [15, 47, 49, 50]. We also notedTable 4 Articles studying mortality in relation to system factorsHospitalvolumeSurgeonvolumeNursingvolumeJulyadmitGeneralanestheticIntensive careadmitShortstayHospitalizationdelaySurgicaldelayBelmont 2014 [15] √*Li 2014 [61] √ √Uzoigwe 2013 [19] √Williams 2013 [36] √ √Neuman 2012 [21] √Pioli 2012 [48] √Vidal 2012 [50] √ √*Tarazona-Santabalbina2012 [47]√* √*Le-Wendling 2012 [20] √Sanz-Reig 2012 [49] √*Daugaard 2012 [18] √Koval 2011 [26] √Peleg 2011 [30] √Schilling 2011 [28] √Carretta 2011 [39] √Forte 2010 [56] √ √Kesmezacar 2010 [67] √Browne 2009 [34] √* √Anderson 2009 [31] √Vidal 2009 [35] √Among all 1 2 1 1 2 1 1 2 9*no statistical association foundSheehan et al. BMC Musculoskeletal Disorders  (2016) 17:166 Page 8 of 13conflicting reports for the association between mortal-ity and both July admission and hospital volume. Theother factors were studied by only one or two studiesincluded in this review.For 7 factors we found a proposed mechanism of theireffects on mortality, Table 6. Complications were pro-posed as a biological mechanism for the mortality effectof nursing staff volume [28] and hospitalization delay[50, 61]. Non-biological mechanisms included surgicaldelay [28], staffing volume [31] and discharge destin-ation [36]. Some proposed included hypothetical media-tors, such as, exposure to inflammatory andhypercoagulable states [71, 72] and inappropriate plan-ning, technique or management [34].Table 5 Proposed mechanisms and mediators for the mortality effect of patient factorsFactor Mechanism MediatorAge Aging reduces the reserve capacity necessary to cope with a double traumaof hip fracture and surgery [22, 37].Hypothesis onlyThe number of chronic conditions increases with age [47, 70]. Extent of comorbiditySex Men present with more comorbidity than women [47, 54, 65, 68]. Extent of comorbidityMen develop delirium [60], lung infection, pneumonia, and septicemiamoreoften than women [54, 68].ComplicationsPrefracture function Patients with poorer pre-fracture ambulatory status often have reducedcardiorespiratory function compared to those with better status [68].Cardiorespiratory functionPatients with a high degree of dependency are more often delayed toadmission than patients with a low degree of dependency [50].Hospitalization delayPatients with poor pre-fracture ambulatory status are quickly placed in nursing homeswhile patients with better status wait in hospital for rehabilitation beds [36].Length of stayPreadmission residence Institutionalized patients develop pneumonia and pressure ulcer more often than patientsfrom community [54, 60].ComplicationsSocioeconomic status Patients with low socioeconomic status are more often delayed to admission than patientswith high socioeconomic status [50].Hospitalization delayClinical stability Patients who are acutely unstable on admission are delayed to surgery more often thanthose who are stable [25, 39].Surgical delayExtent of comorbidity Multiple comorbidities diminish reserves for stresses of surgery and delays recovery [37, 38]. Hypothesis onlyPatients with more comorbidity are delayed to surgery more often than those withless comorbidity [25, 48].Surgical delayPatients with more comorbidity are quickly placed in nursing homes while patientswith less comorbidity wait in hospital for rehabilitation beds [36].Length of stayBody composition Patients with low BMI are more likely to develop adverse cardiac event post hipfracture surgery [66].ComplicationsPatients with low BMI are more likely to be frail [66] and have diminished reservesto cope with the stress of surgery [38].Hypothesis onlyPatients with low BMI often have reduced cardiorespiratory function and a supressedimmune system [38].Immune response,Cardiorespiratory functionHistory ofcerebrovascular accidentPatients with hemiplegia often have more comorbidity and poor pre-fractureambulatory status [68].Extent of comorbidity,Pre-fracture functionDementia Patients with dementia often have more comorbidity and poor pre-fractureambulatory status [68].Extent of comorbidity,Pre-fracture functionDiabetes Diabetes may lead to poor bone remodeling post hip fracture [52]. Bone remodeling [77]Diabetes may lead to poor wound healing post hip fracture surgery [52]. Hypothesis onlyPatients with diabetes may have poor glycemic control leaving the body prone to infectionsand complications after surgery [52].Glycemic control [78]ComplicationsMalnutrition Patients with malnutrition often present with more comorbidity and poor pre-fractureambulatory status.(16;38)Extent of comorbidity,Pre-fracture functionMyocardial infarction Patent foramen ovale allows procoagulant cell conjugates and fragments to passdirectly from the venous to the arterial blood [37].Hypothesis onlySecondaryhyperparathyroidismPatients with secondary hyperparathyroidism often have more comorbidity [51]. Extent of comorbiditySecondary hyperparathyroidism leads to severely altered calcium homeostasis [32]. Calcium homeostasisSheehan et al. BMC Musculoskeletal Disorders  (2016) 17:166 Page 9 of 13DiscussionThe purpose of this review was to synthesize the informa-tion available on proposed mechanisms for reported associa-tions between patient and system factors and mortality afterhip fracture. The articles included in this review point toplausible mediators in the biological mechanisms for mor-tality post fracture: complications, comorbidity, cardiorespi-ratory function, immune function, bone remodeling andglycemic control. For example, exposure to immobilizationand inflammatory states is the proposed mechanism mediat-ing the mortality effect of hospitalization delay [71, 72]. Asargued elsewhere, prolonged immobilization leads to poten-tially fatal complications such as pulmonary embolism andpneumonia while prolonged hypercoagulable inflammationleads to potentially fatal complications including stroke andmyocardial infarction [73].A hypothetical reduction in reserve capacity, wherebya patient cannot withstand the stress of trauma and theirpre-existing comorbidity [38], was proposed as a mech-anism for the mortality effect of comorbidity [22, 37]. Itseems plausible, because numerous studies associatedmortality with coexisting arrhythmia, congestive heartfailure, coronary artery disease, myocardial infarction,anemia and cerebrovascular accident. As noted else-where, patients undergoing hip fracture surgery requirethe reserve capacity to withstand the cardiovascular de-pressant effect of anaesthesia [74]. For those who survivebeyond the short-term, patients with cardiovascular dis-ease more often present with reduced reserve exercisecapacity [75] compromising their rehabilitation potentialand placing them at greater risk of dependency, compli-cations and death [76].Table 6 Proposed mechanisms and mediators for the effect of system factors on mortalityFactor Mechanism MediatorHospital volume Patients admitted to low volume hospitals are often delayed to surgery when compared topatients admitted to high volume hospitals [56].Surgical delayNursing staff volume Higher nurse staffing may prevent or allow early detection of complications [28]. ComplicationsHigher nurse staffing improves operating room availability and shorten time to surgery [28]. Surgical delaySurgeon volume Low volume surgeons may not select appropriate procedure and preoperative planning,intraoperative technique and postoperative management [34].Hypothesis onlySurgical delay Patients who are delayed to surgery are exposed to inflammatory and hypercoagulablestates for longer than those who are not delayed [71, 72].Hypothesis onlyHospitalization delay Patients may receive suboptimal care prior to admission and may develop pressure ulcers,thromboembolism, uncontrolled pain or delirium [50, 61].ComplicationsLength of stay Institutionalized patients have shorter hospital stay than patients from community [36]. Discharge destinationAdmission month Patients admitted in July may be exposed to lower staffing levels in holiday period [31]. Staffing volumeFig. 1 Flow chart of the literature retrieval, review, exclusion and selection with sorting by follow up time. n = number. * = Studies excluded with patientpopulations less than 50 years old, pathological or high impact hip fractures, or whose main independent variables were laboratory tests or operation typeSheehan et al. BMC Musculoskeletal Disorders  (2016) 17:166 Page 10 of 13This is the first scoping review to synthesize the pro-posed biological and hypothetical mechanisms for pa-tient and system factors of mortality following hipfracture. Such synthesis represents a first step towardstransparency about underlying assumptions wheninforming policy on potential interventions to improvesurvival in this vulnerable population.This review is not without limitations. In contrast to asystematic review, where literature is critically appraisedon the methodology, we assess the reviewed articles onlyaccording to the presence of proposed mechanisms forthe reported associations. This is a common approach inscoping reviews where the purpose is to collate the evi-dence on a topic of interest. [5] The search strategy wasrestricted to one database over a 5 year period precedingthe review development to minimize the potential bias-ing effects of surgical advancements [10], and changes indelivery of hip fracture care [11–13]. We excluded arti-cles reporting outcomes of interventions as they do notreflect hip fracture mortality resulting from usual care.These restrictions may result in lacking some articlesboth on factors of mortality and proposed mechanisms.ConclusionsWe synthesized proposed mechanisms for reported asso-ciations between patient and system factors and mortal-ity after hip fracture. We identified complications,comorbidity, cardiorespiratory function, immune func-tion and bone remodeling and glycemic control as plaus-ible mediators in the biological mechanisms formortality post fracture. However, we found that the ma-jority of patient and system factors of mortality post hipfracture were reported by only one or two articles andwith no proposed mechanisms for their effects onmortality. Where reported, underlying mechanisms areoften based on a single article and should be confirmedwith further study. Therefore, one cannot be certainwhether intervening on such factors may produce ex-pected results.Ethical approval and consent to participateNot applicable.Consent for publicationNot applicable.Availability of data and materialsArticles were identified in MEDLINE. All articles in-cluded in the final review are identified in the referencelist. Access to full text for each article is dependent onjournal and institutional constraints.AbbreviationMESH: medical subject headings.Competing interestsPierre Guy has received grants from the Canadian Institutes of HealthResearch, the Natural Sciences and Engineering Research Council of Canada,the Canadian Foundation for Innovation and the British Columbia SpecialistsServices Committee for work around hip fracture care not related to thismanuscript. He has also received fees from the BC Specialists ServicesCommittee (for a provincial quality improvement project on redesign of hipfracture care) and from Stryker Orthopedics (as a product developmentconsultant). He is a board member and shareholder in Traumis SurgicalSystems Inc. and a board member for the Canadian Orthopedic Foundation.He also serves on the speakers’ bureaus of AO Trauma North America andStryker Canada. Katie Jane Sheehan, Boris Sobolev, Trina Stephens and AnnaChudyk declare that they have no competing interests.Authors’ contributionsAll authors contributed to the conception and design of the review. Inaddition KJS, TS, AC contributed to the search development, identification ofpapers and data extraction. KJS, BS and PG contributed to the interpretationof the data extracted. KJS and SB drafted the manuscript. All authors criticallyrevised the manuscript. All authors approved the final version for submission.AcknowledgementsNot applicable.FundingThis research was funded by the Centre for Clinical Epidemiology andEvaluation and the Centre for Hip Health and Mobility, Vancouver, Canada.The funders had no role in the design of the review, the data collection,analysis or interpretation of the data, or in writing the manuscript.Author details1School of Population and Public Health, University of British Columbia,Vancouver, Canada. 2Centre for Hip Health and Mobility, Vancouver, Canada.3Department of Orthopaedics, University of British Columbia, Vancouver,Canada.Received: 28 November 2015 Accepted: 7 April 2016References1. Panula J, Pihlajamaki H, Mattila VM, et al. Mortality and cause of death in hipfracture patients aged 65 or older: a population-based study. BMCMusculoskelet Disord. 2011;12:105.Fig. 2 Examples of mechanisms proposed for patient factors inreviewed articles. Black node indicates the outcome. 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King Jr JT, Goulet JL, Perkal MF, et al. Glycemic control and infections inpatients with diabetes undergoing noncardiac surgery. Ann Surg. 2011;253(1):158–65.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Sheehan et al. BMC Musculoskeletal Disorders  (2016) 17:166 Page 13 of 13

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