Machine learning-based prediction of short-and long-term mortality for shared decision-making in older hip fracture patients: the Dutch Hip Fracture Audit algorithms in 74,396 cases

Background and purpose — Treatment-related shared decision-making (SDM) in older adults with hip fractures is complex due to the need to balance patient-specific factors such as life goals, frailty, and surgical risks. It includes considerations such as prognosis and decisions concerning whether to operate or not on frail, life-limited patients. We aimed to develop machine learning (ML)-driven prediction models for short-and long-term mortality in a large cohort of patients with hip fractures. Methods — In this national registry-based retrospective cohort study, patients aged ≥ 70 years registered in the nationwide Dutch Hip Fracture Audit from 2018–2023 were included. Predictive variables were selected based on the literature and/or clinical relevance. 6 ML algorithms, including logistic regression, were trained with internal cross-validation and evaluated on discrimination (c-statistic), sensitivity, specificity, calibration, and interpretability. Results — 74,396 patients (median age 84, IQR 78–89; 68% female) were analyzed. Most patients lived at home (69%) and high malnutrition risk was seen in 10%. 18% had dementia. Mortality rates were 9.1% (30-day), 15% (90-day), and 26% (1-year). Logistic regression performed comparably to other algorithms, but was chosen as the preferred algorithm due to its superior interpretability (c-statistic: 30-day 0.82, 90-day 0.81, 1-year 0.80). Conclusion — We developed and validated ML algorithms, including logistic regression, for mortality prediction in older hip fracture patients with adequate performance. This information may inform SDM.