Patient and Hospital Factors Affecting the Timing of Hip Fracture Surgery: A Risk-Stratified Analysis in the United States

OBJECTIVE: To determine the proportion of high-risk for surgical delay hip fracture patients who experienced delayed surgery and if associations exist among hospitals achieving timely surgical care in high-risk patients. METHODS: Design: Retrospective cohort. SETTING: National Inpatient Sample (NIS) database. PATIENT SELECTION CRITERIA: Hip fracture patients aged 65 years and older identified using ICD-10 codes in the NIS from 2016 through 2020 were included. OUTCOME MEASURES AND COMPARISONS: The primary outcome was surgery on post-admission day 3 or greater (delayed surgery), compared across patient groups stratified by risk for surgical delay using an established model incorporating Elixhauser Comorbidity score, age, gender, and race. Factors associated with hospital-level surgical delay were assessed using multivariable logistic regression. RESULTS: 1,142,625 patients met the eligibility criteria. Most patients were female (70%) and Medicare beneficiaries (91%). The median patient age was 83 (IQR 76 to 89). The proportion of patients categorized as high-, moderate-, and low-risk for surgical delay were 7%, 81%, and 12%, respectively. Three percent of low-risk patients received surgery on post-admission day 3 or later compared to 7% and 12% of patients in the moderate- and high-risk groups respectively (P<0.01). At 2176 hospitals (62%), all high-risk patients were reported to have their surgery performed within 2 days. At 620 hospitals (18%), 27% of high-risk patients experienced delays of 3 days or more. Compared to hospitals with no surgical delays in their high-risk patients, the highest twentieth percentile of hospitals with surgical delay in high-risk patients were more likely to be teaching hospitals (OR, 1.4; 95% CI, 1.1 to 1.8; P=0.02), located in the Northeast (OR, 1.8; 95% CI, 1.3 to 2.4; P<0.01) or South (OR, 1.6; 95% CI, 1.3 to 2.1; P<0.01), and have a higher proportion of high-risk patients (OR, 3.4; 95% CI, 1.4 to 5.9; P=0.01). CONCLUSIONS: While the majority of patients with a hip fracture in the United States received timely surgery within 2 days, a substantial proportion of high-risk hip fracture patients experienced surgical delays. The causes of these surgical delays remain unclear, whether from resource limitations, time for medical optimization, competing surgical priorities, or systemic factors driving regional variations in care delivery. LEVEL OF EVIDENCE: Prognostic, Level III.