Supplemental Table 1. Variables with missing data, American College of Surgeons National
Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File, 2016.
Variables No. with missing data (%)
Body mass index (kg/m
2) 888 (14.3%)
Preoperative use of mobility aid 282 (4.5%)
Time from admission to operation 220 (3.5%)
Functional status 62 (1.0%)
Transfer status 14 (0.2%)
ASA physical status 11 (0.2%)
Preoperative laboratory data
Hematocrit (%) 16 (0.3%)
White blood cell count 26 (0.4%)
Serum sodium level (mEq/L) 23 (0.4%)
Creatinine (mg/dL) 23 (0.4%)
Abbreviations: ASA, American Society of Anesthesiologists.
Supplemental Table 2. Univariable and multivariable logistic regression analysis for post hip fracture surgery delirium, American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File, 2016.
Characteristics Univariable Analysis Multivariable Analysis OR (95% CI) PValue OR (95% CI) P Value
Age (y) <0.001 <0.001
60-69 (Reference) — —
70-79 1.99 (1.54-2.57) <0.001 1.62 (1.21-2.17) 0.001
80-89 3.28 (2.58-4.15) <0.001 2.01 (1.51-2.66) <0.001
≥ 90 4.37 (3.42-5.58) <0.001 2.31 (1.71-3.11) <0.001
Sex 0.45
Female (Reference) —
Male 1.05 (0.93-1.18)
ASA physical status <0.001 0.008
I-II (Reference) — —
III-V 2.20 (1.84-2.64) 1.34 (1.08-1.67)
Body mass index (kg/m2) <0.001
BMI ≤ 18.5 (Reference) —
BMI > 18.5 and ≤25 0.86 (0.70-1.07) 0.17 BMI >25 and ≤30 0.72 (0.57-0.90) 0.004 BMI >30 and ≤35 0.64 (0.49-0.84) 0.001
BMI >35 0.58 (0.41-0.83) 0.002
missing 0.96 (0.76-1.22) 0.75
Functional status <0.001 <0.001
Independent (Reference) — —
Partially/Totally
dependent 2.91 (2.57-3.30) 1.35 (1.15-1.60)
Transfer status <0.001
Admitted from home (Reference)
— Chronic care facility 2.49 (2.12-2.92)
Other 1.26 (1.07-1.48)
Smoking within one year 0.76 (0.63-0.93) 0.007 1.39 (1.09-1.77) 0.008
Diabetes 0.88 (0.76-1.02) 0.1 0.87 (0.73-1.05) 0.15
Dyspnea 1.24 (1.02-1.52) 0.03 1.25 (0.98-1.59) 0.07
COPD 1.15 (0.97-1.37) 0.11
Pneumonia 2.74 (1.59-4.71) <0.001 2.84 (1.31-6.16) 0.008
Ascites 1.62 (0.66-3.96) 0.29
Congestive heart failure 1.36 (1.05-1.76) 0.02
Hypertension 1.17 (1.04-1.31) 0.01 1.11 (0.95-1.29) 0.18 Acute renal failure 1.48 (0.70-3.14) 0.31
Preoperative dialysis 0.93 (0.63-1.39) 0.74 Disseminated cancer 0.55 (0.37-0.82) 0.003 Wound infection 1.44 (1.10-1.89) 0.008
SIRS/Sepsis/septic shock 1.77 (1.49-2.10) <0.001 1.39 (1.12-1.73) 0.003 Chronic steroid use 0.77 (0.60-0.99) 0.04
Unintentional weight loss 1.51 (0.96-2.37) 0.07
Bleeding disorder 1.28 (1.12-1.47) <0.001 1.26 (1.07-1.49) 0.007 Preoperative transfusion 1.10 (0.86-1.41) 0.43
Preoperative laboratory data Hematocrit, per 1%
increase
1.00 (0.99-1.01) 0.38 WBC, per 1 × 109/L
increase
1.03 (1.01-1.04) <0.001
Serum sodium level 1.59 (1.33-1.89) <0.001 1.20 (0.96-1.49) 0.11 ( Na ≥ 143 mEq/L)
Creatinine > 0.95 mg/dl 1.33 (1.19-1.48) <0.001 1.20 (1.05-1.38) 0.009 Preoperative delirium 13.91 (11.54-16.77) <0.001 9.07 (7.27-11.32) <0.001 Preoperative dementia 4.79 (4.26-5.40) <0.001 2.49 (2.13-2.91) <0.001 Pre-fracture bone
protection medication
1.32 (1.17-1.48) <0.001 Preoperative use of
mobility aid
2.05 (1.82-2.31) <0.001 1.27 (1.10-1.47) 0.001 Preoperative pressure sore 1.73 (1.31-2.29) <0.001 1.25 (0.88-1.78) 0.22 Medical co-management 1.73 (1.41-2.12) <0.001 1.46 (1.15-1.86) 0.002 Standardized hip fracture
care program
1.09 (0.97-1.21) 0.15 1.14 (1.00-1.31) 0.05
Emergency 0.90 (0.80-1.01) 0.06
Time from admission to operation
0.008 0.11
≤ 1 day (Reference) —
> 1 day 1.20 (1.05-1.37) 0.88 (0.74-1.03)
Type of hip fracture 0.01
Femoral neck fracture
-undisplaced 0.86 (0.70-1.05) Femoral neck fracture
-displaced 1.07 (0.94-1.21)
Intertrochanteric
(Reference) —
Subtrochanteric 0.70 (0.54-0.89) Other/Cannot be
determined
0.93 (0.65-1.32)
Pathologic fracture 0.002
None (Reference) —
Tumor 0.52 (0.30-0.90)
Atypical 0.44 (0.24-0.80)
Abbreviations: CI, confidence interval; OR, odds ratio; ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease;
SIRS, systemic inflammatory response syndrome; WBC, white blood cell; Na, sodium; BUN, blood urea nitrogen; Cr, creatinine.
Variables in bold were used in stepwise multivariable logistic regression.
Supplemental Table 3. Comparison of the area under the curve of the receiver operator
characteristic curves with sequential removal of variables, American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File, 2016.
Model Variables AUC
(95% CI)
Comparison Difference in AUC
(95% CI) Pa Value M 19 M 18 and
diabetes
0.777 (0.763-0.790)
M 19 vs.
M 18
0.0004 (-0.001 - 0.001)
0.41
M 18 M 17 and time to operation
0.776 (0.763-0.790)
M 18 vs.
M 17
-0.0003 (-0.001 - 0.001)
0.59
M 17 M 16 and hypertension
0.777 (0.763-0.790)
M 17 vs.
M 16
0.0002 (-0.001 - 0.001)
0.58
M 16 M 15 and standardized hip
fracture care program
0.776 (0.763-0.790)
M 16 vs.
M 15
0.0006 (-0.001 - 0.002)
0.32
M 15 M 14 and creatinine level
0.776 (0.762-0.789)
M 15 vs.
M 14
0.0001 (-0.001 - 0.001)
0.86
M 14 M 13 and sodium level
0.776 (0.762-0.789)
M 14 vs.
M 13
0.001 (-0.001 - 0.003)
0.23
M 13 M 12 and dyspnea
0.775 (0.761-0.788)
M 13 vs.
M 12
0.0003 (-0.001 - 0.002)
0.69
M 12 M 11 and preoperative pressure sore
0.774 (0.761-0.788)
M 12 vs.
M 11
-0.0001 (-0.001 - 0.001)
0.89
M 11 M 10 and bleeding disorder
0.774 (0.761-0.788)
M 11 vs.
M 10
0.001 (-0.001 - 0.003)
0.21
M 10 M 9 and use of mobility aid
0.773 (0.759-0.787)
M 10 vs.
M 9
0.004 (0.001 - 0.007)
0.008
M 9 M 8 and ASA physical status
0.769 (0.755-0.783)
Abbreviations: CI, confidence interval; AUC, area under the curve; ASA, American Society of
Anesthesiologists; SIRS, systemic inflammatory response syndrome.
Model 8: preoperative delirium, pneumonia, preoperative dementia, age, medical co-management, smoking, SIRS/Sepsis/Septic shock, and functional dependence.
aP Value for difference in AUC of receiver operator characteristic curve.
Supplemental Table 4. Multivariable logistic regression analysis for post hip fracture surgery delirium, American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File, 2016.
Variables OR (95% CI) P Value
Preoperative delirium 8.27 (6.74-10.15) <0.001
Pneumonia 1.64 (0.84-3.23) 0.15
Preoperative dementia 2.39 (2.06-2.77) <0.001
Age (y) <0.001
60-69 (Reference) —
70-79 1.60 (1.20-2.12)
80-89 2.09 (1.59-2.75)
≥ 90 2.42 (1.82-3.23)
Medical co-management 1.43 (1.13-1.80) 0.003
Smoking 1.36 (1.07-1.72) 0.011
SIRS/Sepsis/Septic shock 1.33 (1.07-1.64) 0.009
Functional status <0.001
Independent (Reference) —
Partially/Totally dependent 1.37 (1.17-1.61)
ASA physical status 0.002
I-II (Reference) —
III-V 1.40 (1.13-1.73)
Preoperative use of mobility aid 1.32 (1.14-1.52) <0.001 Abbreviations: CI, confidence interval; OR, odds ratio; ASA, American Society of Anesthesiologists; SIRS, systemic inflammatory response syndrome.
Supplemental Table 5. Estimated probability of post hip fracture surgery delirium by risk score,
American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File, 2016.
Total points Estimated probability of delirium, %
0 4.5
1 5.8
2 7.5
3 9.6
4 12.3
5 15.6
6 19.6
7 24.3
8 29.7
9 35.7
10 42.3
11 49.1
12 56.0
13 62.6
14 68.8
15 74.4
16 79.3
17 83.4
18 86.9
19 89.7
20 92.0
Supplemental Table 6. Multivariable logistic regression analysis for post hip fracture surgery delirium in patients without preoperative delirium, American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File, 2016.
Variables OR (95% CI) P Value
Pneumonia 2.05 (0.99-4.24) 0.053
Preoperative dementia 2.44 (2.08-2.86) <0.001
Age (y) <0.001
60-69 (Reference) —
70-79 1.63 (1.21-2.21)
80-89 2.07 (1.55-2.77)
≥ 90 2.49 (1.83-3.37)
Smoking 1.42 (1.11-1.83) 0.005
SIRS/Sepsis/Septic shock 1.39 (1.11-1.75) 0.004
Functional status <0.001
Independent (Reference) —
Partially/Totally dependent 1.34 (1.13-1.59)
ASA physical status 0.017
I-II (Reference) —
III-V 1.32 (1.05-1.66)
Preoperative use of mobility aid 1.38 (1.18-1.61) <0.001
Dyspnea 1.30 (1.02-1.66) 0.036
Bleeding disorder 1.26 (1.06-1.49) 0.008
Creatinine > 0.95 mg/dl 1.19 (1.03-1.37) 0.015
Pre-fracture bone protection medication 1.12 (0.97-1.30) 0.14
Hypertension 1.10 (0.95-1.29) 0.21
Disseminated cancer 0.68 (0.41-1.14) 0.14
Abbreviations: CI, confidence interval; OR, odds ratio; ASA, American Society of Anesthesiologists; SIRS, systemic inflammatory response syndrome.
Patients in ACS-NSQIP Hip Fracture File 2016 (N=9,390)
Exclusion:
Patients aged less than 60 years (N=519)
Hip Fracture Cohort (N=8,871)
Derivation Cohort (N=6,210)
Validation Cohort (N=2,661)
Supplemental Figure 1
Supplemental Figure 1.
Selection of hip fracture patients, American
College of Surgeons National Surgical Quality Improvement Program
(ACS-NSQIP) Hip Fracture Targeted Participant Use Data File, 2016.
A
Supplemental Figure 2
Supplemental Figure 2. Receiver operator characteristic (ROC) curves of risk score model
for post hip fracture delirium (PHFD) in derivation and validation cohorts (A). Calibration plots showing observed and predicted PHFD risk across the range of risk scores (0-20) for derivation (B), validation (C) and test cohorts (D).
D B
C
0.0 0.5 1.0
0.0 0.5 1.0
1 - Specificity
Sensitivity
Validation [AUC 0.77 (95% CI 0.75-0.79)]
Derivation [AUC 0.77 (95% CI 0.76-0.78)]
Test [AUC 0.79 (95% CI 0.77-0.80)]
0.0 0.5 1.0
0.0 0.5 1.0
Predicted PHFD
Observed PHFD
0.0 0.5 1.0
0.0 0.5 1.0
Predicted PHFD
Observed PHFD
0.0 0.5 1.0
0.0 0.5 1.0
Predicted PHFD
Observed PHFD
