Early surgery within 2 days for hip fracture is not reliable as healthcare quality indicator

Abstract

Purpose

To analyze prospectively the influence of the timing of surgery on morbidity and mortality, and to assess whether the early surgery within 2 days admission may be a reliably healthcare quality indicator.

Methods

Prospective observational study of 628 patients age 60 or older who had been co-managed between surgeons and internists. Based on the literature, many potential factors influencing outcomes were collected to control confounding regard to surgery delay, complications and mortality. Multivariate logistic regression and Cox regression models were used to assess effects on the delay and mortality, respectively.

Results

Mean Charlson index was 2.3, and 284 patients had at least 3 comorbidities. Mean timing of surgery was 3.6 days (range 0–20). 418 patients were fit for surgery, of which 180 underwent surgery within 2 days. Delay for surgery more than 2 days was significantly associated with ASA >2, Charlson >2 and anticoagulant therapy. Medical complications were not significantly associated with delayed surgery more than 2 days. Mortality rate was 0.9% in-hospital, 3.4 at 1 month, 7.0% at 3 months, and 13.6% at 12 months. There were no significant differences in in-hospital, 3-month or 1-year mortality between patients operated within 2 days and those operated at 3–4 days, but delayed more than 4 days was associated with higher 1-year mortality. Likewise, patients readmitted within 30 days had higher in-hospital mortality. Excluding unfit for surgery patients at admission, there was no significant difference in 3-month or 1-year mortality between patients operated within 2 days and those with delayed surgery.

Conclusions

Delaying surgery up to 4 days was not associated with higher morbidity or mortality rates. 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.

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.