Early surgery within 2 days for hip fracture is not reliable as healthcare quality indicator
Introduction
Hip fractures are an important medical and social problem because of the high incidence in elderly population. There is a high consensus that surgery is the treatment of choice for these patients to reduce postinjury mortality and provide effective functional results for the remaining years of life [1]. The prognostic factors reported in the literature are very varied [2], and the timing of surgery has been described as a main factor with influence on postoperative morbidity and mortality. Several studies and systematic reviews have reported that early surgery within 48 h after admission was associated with lower postoperative morbidity and mortality [1], [3], [4]. On this basis, current guidelines [5], [6] recommend early surgery within 2 days after admission. Likewise, some hospitals and health administrators [7], [8], including our country [9], have set the hip fracture surgery within 2 days as a reliable indicator of quality of healthcare. However, although hip fracture in elderly and prognostic factors have been widely studied, the suitable time to surgery is still a controversial topic, and the association between this time and postoperative complications or mortality appears to be unclear. This is probably because there are limited available quality evidences and the results are conflicting [1].
The most studies were retrospective and they did not take account those patients who were unfit for surgery at the time of admission and failed to adjust confounding factors such as coexisting comorbidities. Thus, these studies could be susceptible to selection bias and this could lead to an overestimating the risk of death associated with delayed surgery. There are few prospective studies [10], [11], [12], [13], [14], [15] but they had different objectives and varied study time periods. On the other hand, recent studies [9], [16] found that morbidity increased but the mortality rate did not when surgery was delayed more than 2 days. Likewise, other studies [2] reported that delay of surgery had no impact on mortality when this was adjusted in terms of other risk factors such as comorbidities. On the contrary, precipitous surgery may increase the risk of postoperative complications [11], [13] because delaying surgery may be necessary to stabilize patients with significant comorbidities. Thus, our hypothesis was that delayed surgery may not be a result of poor healthcare quality but rather to optimize preoperatively clinical conditions of those patients with severe comorbidities.
The objectives of this study were to analyze prospectively the influence of the timing of surgery on morbidity and mortality at one year, and to assess whether the early surgery within 2 days after admission may be reliably used as an indicator of medical care quality.
Section snippets
Material and methods
A prospective observational study was designed to evaluate prognostic after hip fracture in elderly, which was approved by our institutional ethics committee and informed consent was required. All consecutive patients with hip fractures admitted at our hospital between January 2012 and December 2014 were potentially eligible. The only inclusion criterion was age 60 years or older. The exclusion criteria were concurrent major injuries or nonsurgical treatment (ASA-V, decision to palliative care,
Results
Between January 2012 and December 2014, 674 patients with hip fracture were admitted. Of them, 46 were excluded for study (30 under 60 years, 14 with nonsurgical treatment, and 2 patients who died before surgery could be performed). The remaining 628 patients were the subjects of this study. The mean age was 83.5 years (range, 61–102), 76.9% of patients were age 80 or older. There were 74.2% females. The mean age among females was 83.9 (standard deviation, 6.8) and among males 82.4 (sd, 8.3) (p =
Discussion
The impact of the timing of surgery for hip fractures in elderly on mortality has been widely studied but remains controversial. Current guidelines [5], [6] recommend early surgery within 2 days after admission to reduce length of hospital stay, complications and mortality, and this strict number has been set as a quality of healthcare indicator. However, there was a lack of quality evidences on this topic and most recent studies have provided conflicting results [1]. Most studies were
Conclusion
The results of this study confirm our hypothesis that the rate of hip fracture patients undergoing surgery within 2 days has not proven to be a reliable indicator for medical care quality. Delaying surgery up to 4 days did not influence the occurrence of complications and mortality in the short or long-term.
We recommend concentrating more on preoperative optimizing the condition of patient with sufficient medical treatment rather than being bound by a universal timing of surgery.
Conflict of interest
The authors declare that they have no conflict of interest.
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