Early postoperative anxiety is associated with patient-reported recovery after hip fracture: A PROMIS-based longitudinal cohort study.

BACKGROUND

Hip fractures in older adults result in substantial functional decline. While physical factors influencing recovery are well established, the role of early postoperative psychological distress remains incompletely understood. We examined whether early postoperative anxiety was associated with achievement of minimal clinically important difference (MCID) in patient-reported recovery after hip fracture.

METHODS

We conducted a retrospective cohort study of patients aged > 55 years with native hip fracture treated operatively between 2015 and 2024 who completed PROMIS assessments. Baseline PROMIS assessments were defined as the first available domain-specific assessment during postoperative days 0-30. The primary outcome was MCID achievement in PROMIS Physical Function (PF) and Pain Interference (PI) using the final available assessment from postoperative days 31-365. A late-recovery sensitivity analysis restricted final follow-up to postoperative days 91-365. MCID was defined as a > =5-point improvement in PF or > =5-point reduction in PI. Multivariable logistic regression adjusted for baseline domain score, baseline anxiety, age, and Charlson Comorbidity Index (CCI).

RESULTS

The primary PF cohort included 304 patients, of whom 171 (56.3%) achieved MCID. The primary PI cohort included 285 patients, of whom 169 (59.3%) achieved MCID. Higher early postoperative anxiety was associated with lower odds of PF MCID achievement (OR per T-score point 0.960, 95% CI 0.933-0.988; p = 0.005; C-statistic 0.812, 95% CI 0.761-0.862) and PI MCID achievement (OR 0.968, 95% CI 0.937-0.999; p = 0.046; C-statistic 0.759, 95% CI 0.702-0.815). In the late-recovery sensitivity analysis restricted to postoperative days 91-365, associations remained directionally adverse but did not reach statistical significance (PF N = 210, OR 0.970, 95% CI 0.938-1.003; p = 0.074; PI N = 177, OR 0.967, 95% CI 0.927-1.008; p = 0.116).

CONCLUSIONS

Higher early postoperative PROMIS Anxiety was associated with lower odds of clinically meaningful improvement in PF and PI during first-year follow-up after hip fracture. Associations were directionally consistent but less precise when follow-up was restricted to later postoperative assessments. These findings support early postoperative anxiety as a recovery risk marker and highlight the need for prospective studies to determine whether anxiety-targeted interventions improve outcomes after hip fracture.