Hip Surgery Delays Increase Mortality Risk in Older Patients

Hip fracture surgery for medically stable elderly patients should occur the day of hospital admission or the next day, the findings of a new study suggest.

In an analysis of data on nearly 140,000 patients in 144 hospitals across Canada, delaying hip fracture surgery until inpatient day 3 or longer was associated with a projected increase in mortality of approximately 11 deaths per 1000 procedures compared with surgery performed on the day of admission, the researchers write in an article published online August 7 in the Canadian Medical Association Journal.

The findings "allow us to infer a critical point for the timing of hip fracture repair," Pierre Guy, MD, an orthopedic surgeon at the Centre for Hip Health, the University of British Columbia, Vancouver, Canada, and one of the principal investigators, said in a news release about the study. "We suggest that clinicians, administrators, and policy-makers 'not let the sun set twice' on medically stable older adults before their hip fracture repair."

The authors suggest that hospital policies be revised to allow all medically stable older adults to undergo hip fracture surgery on the day of or after admission. "This approach places the emphasis of managerial efforts on expediting operating room access for patients whose surgery might be delayed for nonmedical reasons," they write.

Nonmedical Delays Common

The point at which postponing surgery for nonmedical reasons hastens mortality has become the focus of "considerable debate," the authors explain.

Medically stable patients often see their surgery delayed because an operating room or a surgeon is not readily available. This occurs despite a benchmark adopted in 2005 by Canadian provincial, territorial, and federal governments stating that 90% of hip fracture surgeries should be performed within 48 hours of admission.

In this study, Boris Sobolev, PhD, from the School of Population and Public Health, the University of British Columbia, Vancouver, and colleagues analyzed the discharge data of all patients aged 65 years or older who underwent hip fracture surgery in Canada (except Quebec) between January 1, 2004, and December 31, 2012. The study excluded patients with medical conditions that might affect the timing of surgery.

The authors defined the outcome as "any death within 30 inpatient days after surgery, reported per 1000 surgeries," and adjusted for potential confounding variables including treatment era, hospital type, procedure type, age at admission, prefracture health status, and surgical readiness.

The analysis included 139,119 patients at 38 teaching and 106 community hospitals. Of these patients, 103,405 (74.3%) were women, and 63,786 (45.8%) were aged 85 years or older. Transcervical fracture was the reason for 72,285 (52.0%) of the surgeries, and 84,643 (60.1%) procedures involved fixation.

Patients who underwent prompt surgery "were less likely to have been admitted from home with comorbidities, were less likely to have been transferred, and were more likely to undergo fixation, with the percentage of patients who were transferred increasing and the percentage of patients with fixation declining as the time to surgery increased," the researchers explain. Within 30 days of surgery, 89,782 patients (64.5%) had been discharged alive, and 6371 (4.6%) had died.

When expressed as cumulative 30-day mortality, there were 48.9 deaths per 1000 procedures performed on the day of admission, and 48.0 deaths per 1000 procedures performed on day 2 of admission. After that, cumulative mortality rose significantly, to 57.0 deaths per 1000 procedures performed on inpatient day 3, and 69.1 deaths per 1000 surgeries performed thereafter.

Had all surgeries been performed on the day of admission, the expected mortality would be 43.3 (95% confidence interval [CI], 40.9 - 45.6) per 1000 surgeries, the authors add. That number would fall slightly, to 42.6 (95% CI, 41.0 - 44.3) per 1000 procedures, if performed on inpatient day 2, and then rise to 49.0 (95% CI, 46.5 - 51.6) deaths per 1000 surgeries performed on inpatient day 3, and then even more sharply to 54.2 (95% CI, 50.8 - 57.7) deaths per 1000 surgeries performed after inpatient day 3.

Overall, if all surgeries were performed on inpatient day 3 rather than the day of admission, an additional 5.8 (95% CI, 2.3 - 9.2) patients per 1000 surgeries would die, and that number would rise further, to 10.9 (95% CI, 6.8 - 15.1) deaths for every 1000 surgeries if all surgeries took place after inpatient day 3. When compared with surgery on the day of admission, the marginal odds ratio of mortality on inpatient day 2 was 0.98 (95% CI, 0.92 - 1.05), rising to 1.14 (95% CI, 1.05 - 1.23) on inpatient day 3 and to 1.27 (95% CI, 1.16 - 1.38) for surgery after inpatient day 3.

The researchers estimate that the proportion of in-hospital deaths resulting from surgical delays later than inpatient day 2 was 16.5%.

Outside Experts Concur

Two experts not involved in this research agreed this study addresses an ongoing source of concern among orthopedic surgeons. "This is an issue we've been wrestling with for a long time," David Helfet, MB, ChB, an orthopedic trauma surgeon at the Hospital for Special Surgery, New York City, told Medscape Medical News. "I think these authors prove what we believe conceptually: that elderly patients lying immobile awaiting surgery is not a good scenario, and if they are medically stable enough for a procedure and an anesthetic, the sooner you do it, the better."

Although there is general agreement that earlier surgery is better, "the problem is logistics and institutions," Helfet said. Larger hospitals with multiple operating rooms and large staffs may find it easier to expedite things, but smaller, more rural hospitals may struggle to achieve this goal. "If you only have one operating room and that's already being used for trauma surgery or vascular surgery or abdominal surgery, it gets a little more difficult," he explained.

Sometimes the challenge is to determine whether a patient is medically stable, especially when that patient is in their 70s or older, Helfet added. "I think the real value of this study is to show that as soon as you feel comfortable doing the surgery from a medical and anesthesia standpoint, and you have a team and an operating room available, you should do the surgery in an expeditious fashion."

This study "is as good as it gets. They gathered information on over 100,000 patients," Helfet said. "I would congratulate these authors and the system in which they worked; these studies are difficult to do."

The findings have "potentially powerful implications for the timing of hip fracture surgery," Kelly Hynes, MD, assistant professor of orthopedic surgery, University of Chicago School of Medicine, Illinois, told Medscape Medical News. "There was still a significant difference in 30-day mortality with delay of surgery, despite removing many of the medical comorbidities that would typically lead to an increased mortality risk in this population. The large population included in the study adds power to the results, suggesting that the differences noted are important."

Hynes also agreed that hospitals should consider revising policies and reallocating resources to permit more timely performance of hip fracture surgery whenever possible. "Moving forward from the results of this study, a definitive way to determine the effect of timing on patient safety and mortality requires a large, prospective trial," she added. "I do think this study is getting us closer to the truth."

Study Limitations

The reliance on administrative data may have led to underreporting of comorbidities and misclassification of medical delays, the authors write. In addition, information on the time between sustaining the injury and arriving at the hospital was not available, which might have had an effect on outcomes. Also, "we were unable to differentiate between surgeries done during and after working hours," leading to questions about possible fatigue and greater risk for errors among medical staff working at night. Nor did they distinguish between urban and rural hospitals or teaching and community hospitals and the "unobserved variation in care delivery" that might occur in facilities of different types. Finally, they write, there may have been uncertainties in the determination of prefracture health status.

One of the study authors reports receiving fees from the BC Specialists Services Committee for a provincial quality improvement project on redesign of hip fracture care, from Stryker Orthopaedics as a product development consultant, and is a board member and shareholder in Traumis Surgical Systems Inc and a board member for the Canadian Orthopaedic Foundations. He also serves on the speakers' bureaus of AOTrauma North America and Stryker Canada. Another author reports receiving research grants from Amgen Canada, and two other authors report receiving research grants from the Canadian Institutes of Health Research during the conduct of the study. No other competing interests were declared.

CMAJ. Published online August 7, 2018. Abstract

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