What is the clinical evidence from this study?

Study design: Cohort. Population: Hip fracture (n=139119). Intervention: Surgical delay after inpatient day 3 vs. Surgery on day of admission. Primary outcome: 30-day in-hospital mortality (OR 1.27, 95% CI 1.16 to 1.38).

August 7, 2018Open Access

Mortality effects of timing alternatives for hip fracture surgery

Key Result

Delaying hip fracture surgery until after inpatient day 3 increased 30-day in-hospital mortality compared to surgery on the day of admission (OR 1.27).

Study Design

Type

Cohort (n=139,119)

Multicenter

Yes

Structured PICO

Does early hip fracture surgery (on admission day or day 2) reduce 30-day inpatient mortality compared to delayed surgery in medically stable patients aged 65 or older?

Population

139,119 medically stable adults aged 65 years or older with first-time hip fracture in Canada, followed for 30 days post-surgery.

Exposure

Hip fracture surgery on admission day or inpatient day 2

Comparator

Hip fracture surgery on day 3 or after day 3

Outcome

Inpatient death within 30 dayshard clinical

Surgery on admission day or the following day reduces postoperative mortality among medically stable older patients with hip fracture.

Main Result

Odds Ratio: 1.27 (95% CI 1.16–1.38)

Absolute Event Rate: 6.9% vs 4.9%

Limitations

Use of administrative data may have led to misclassification of medical delays and underreporting of comorbidity.
Available data omitted renal disease, cerebrovascular accident, and dementia.
Analysis does not account for deaths that occurred before surgery could be done.
Lacked data on time between injury and arrival at the hospital.
Unable to differentiate between surgeries done during and after working hours.

Abstract

BACKGROUND: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay. METHODS: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram. RESULTS: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval CI 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%). INTERPRETATION: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.

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