The clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups.
To assess the effect of surgical delay on hospital outcomes according to the cause of delay.
Prospective cohort study.
A hip fracture unit in a university hospital in Spain.
2250 consecutive elderly patients with hip fracture.
Time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications.
Median time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found.
This was a single-center study without postdischarge follow-up.
The reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.
[Show abstract][Hide abstract] ABSTRACT: Proximal femoral fractures are common in the elderly. The best care depends on expeditious presentation, medical stabilization, and treatment of the condition.
We investigated the risk of increased mortality in residents of rural communities secondary to inaccessible facilities and treatment delays.
We used Medicare Provider Analysis and Review Part A data to identify 338,092 patients with hip fractures. Each patient was categorized as residing in urban, large rural, or small rural areas. We compared the distance traveled, mortality rates, time from admission to surgery, and length of stay for patients residing in each location.
Patients in rural areas traveled substantially farther to reach their treating facility than did urban patients: mean, 34.4 miles for small rural, 14.5 miles for large rural, and 9.3 miles for urban. The adjusted odds ratios for mortality were similar but slightly better for urban patients for in-hospital mortality (small rural odds ratio, 1.05; large rural odds ratio, 1.13). Rural patients had a favorable adjusted odds ratio for 1-year mortality when compared with urban patients (small rural odds ratio, 0.93; large rural odds ratio, 0.96). Rural patients experienced no greater delay in time to surgery or longer hospital length of stay.
Although patients living in rural areas traveled a greater distance than those living in urban centers, we found no increase in time to surgery, hospital length of stay, or mortality.
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 10/2011; 470(6):1763-70. DOI:10.1007/s11999-011-2140-3 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fragility fractures, and in particular those of the femoral neck, vertebrae, wrist and proximal humerus, are increasing, with a socio-economic impact strong enough to suggest modifications in their current management. These fractures are characterized by their time of event, clinical approach and functional results, which are also influenced by co-morbidity of the patient. However, in Italy, it was recently shown that patients hospitalized for hip fracture, as well as having an average age over 75, are averagely in their fourth fracturative episode. The high mortality rate usually associated to this type of fracture is significantly decreased when an anti-osteoporosis therapy is initiated. Given the increase of the elderly population in the coming years, and especially the octogenarians, it is necessary to implement a multidisciplinary therapeutic approach suitable to the recovery of a quality of life of the same level to the period preceding the fragility fracture. Therefore, during the first fragility fracture, the orthopedist is essential to implement an adjuvant drug therapy that promotes healing and begins to improve bone quality, with the aim of reducing the risk of further fractures.
Archivio di Ortopedia e Reumatologia 12/2011; 122(3-4). DOI:10.1007/s10261-011-0035-1
[Show abstract][Hide abstract] ABSTRACT: While the benefits or otherwise of early hip fracture repair is a long-running controversy with studies showing contradictory results, this practice is being adopted as a quality indicator in several health care organizations. The aim of this study is to analyze the association between early hip fracture repair and in-hospital mortality in elderly people attending public hospitals in the Spanish National Health System and, additionally, to explore factors associated with the decision to perform early hip fracture repair.
A cohort of 56,500 patients of 60-years-old and over, hospitalized for hip fracture during the period 2002 to 2005 in all the public hospitals in 8 Spanish regions, were followed up using administrative databases to identify the time to surgical repair and in-hospital mortality. We used a multivariate logistic regression model to analyze the relationship between the timing of surgery (< 2 days from admission) and in-hospital mortality, controlling for several confounding factors.
Early surgery was performed on 25% of the patients. In the unadjusted analysis early surgery showed an absolute difference in risk of mortality of 0.57 (from 4.42% to 3.85%). However, patients undergoing delayed surgery were older and had higher comorbidity and severity of illness. Timeliness for surgery was not found to be related to in-hospital mortality once confounding factors such as age, sex, chronic comorbidities as well as the severity of illness were controlled for in the multivariate analysis.
Older age, male gender, higher chronic comorbidity and higher severity measured by the Risk Mortality Index were associated with higher mortality, but the time to surgery was not.
BMC Health Services Research 01/2012; 12(1):15. DOI:10.1186/1472-6963-12-15 · 1.71 Impact Factor
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