Orthopedics

Feature Article 

Timing of Hip Fracture Surgery and 30-Day Outcomes

Michael E. Neufeld, MD; Nathan N. O'Hara, MHA; Min Zhan, PhD; Yongliang Zhai, PhD; Henry M. Broekhuyse, MD, FRCSC; Kelly A. Lefaivre, MD, MSc, FRCSC; Joshua M. Abzug, MD; Gerard P. Slobogean, MD, MPH, FRCSC

Abstract

The goal of this study was to determine the proportion of patients admitted with a hip fracture to participating American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals who were treated within the United Kingdom's National Institute for Health and Care Excellence (NICE) time-to-hip-fracture-surgery benchmark. The secondary goals were to identify factors associated with missing the benchmark and to determine whether the benchmark was associated with improved 30-day patient outcomes. Patients aged 60 years or older who underwent hip fracture surgery between 2005 and 2013 were identified from the ACS-NSQIP database. Of the 26,066 patients who met the enrollment criteria, 71.4% were treated within the NICE benchmark. Many variables, including sex, race, procedure type, and hip fracture diagnosis, were statistically significant predictors of missing the benchmark (P<.001). Meeting the NICE benchmark was not associated with reductions in major complications (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83–1.05; P=.234); however, it was associated with reductions in 30-day mortality (OR, 0.88; 95% CI, 0.78–0.99; P=.028), minor complications (OR, 0.92; 95% CI, 0.84–0.995; P=.038), and postoperative length of stay (beta=−0.77; P<.001). Current practice at participating ACS-NSQIP hospitals is compatible with the NICE time-to-surgery benchmark. However, the findings highlight the importance of further prospective investigation to monitor the effect of early-treatment benchmarks on 30-day patient outcomes. [Orthopedics. 2016; 39(6):361–368.]

Abstract

The goal of this study was to determine the proportion of patients admitted with a hip fracture to participating American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals who were treated within the United Kingdom's National Institute for Health and Care Excellence (NICE) time-to-hip-fracture-surgery benchmark. The secondary goals were to identify factors associated with missing the benchmark and to determine whether the benchmark was associated with improved 30-day patient outcomes. Patients aged 60 years or older who underwent hip fracture surgery between 2005 and 2013 were identified from the ACS-NSQIP database. Of the 26,066 patients who met the enrollment criteria, 71.4% were treated within the NICE benchmark. Many variables, including sex, race, procedure type, and hip fracture diagnosis, were statistically significant predictors of missing the benchmark (P<.001). Meeting the NICE benchmark was not associated with reductions in major complications (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83–1.05; P=.234); however, it was associated with reductions in 30-day mortality (OR, 0.88; 95% CI, 0.78–0.99; P=.028), minor complications (OR, 0.92; 95% CI, 0.84–0.995; P=.038), and postoperative length of stay (beta=−0.77; P<.001). Current practice at participating ACS-NSQIP hospitals is compatible with the NICE time-to-surgery benchmark. However, the findings highlight the importance of further prospective investigation to monitor the effect of early-treatment benchmarks on 30-day patient outcomes. [Orthopedics. 2016; 39(6):361–368.]

The annual incidence of hip fractures is estimated at 250,000 in the United States and more than 1.6 million worldwide and is predicted to double by the year 2040.1–3 Hip fractures are associated with significant patient morbidity and 1-year and 30-day mortality rates of 12% to 36% and 5% to 11%, respectively.1,2 The effect of early surgery on hip fracture outcomes has received considerable study, and although research suggests that early surgical treatment of these fractures leads to better patient outcomes, studies to date are inconclusive.4–26 Time-to-hip-fracture-surgery benchmarks remain a subject of much debate because supporting evidence is limited by methodology and selection bias.27

British and Canadian health care systems have focused considerable attention on the time to surgery as a key measure. In 2010, the England and Wales Department of Health Best Practice Tariff began providing financial incentives for operating on patients with hip fractures within 36 hours.28 Subsequently, the United Kingdom's National Institute for Health and Care Excellence (NICE) issued hip fracture management guidelines in 2011 that recommend that surgery be performed on the day of or the day after admission, resulting in reduced rates of mortality and morbidity and shorter hospital stays.6,29 Currently, no national benchmarks exist in the United States; however, they are being sought. With the passage of the Patient Protection and Affordable Care Act (PPACA), there has been increased attention on quality and cost of care provided.30 This has led to the Centers for Medicare and Medicaid Services penalizing hospitals based on readmission rates and complications in arthroplasty, and this will soon commence in hip fracture care.31

In 2005, the American College of Surgeons (ACS) initiated the National Surgical Quality Improvement Project (NSQIP), a high-quality, prospectively collected, risk-adjusted, multi-center surgical database.32,33 The ACS-NSQIP currently has 660 participating hospitals contributing data to the database, with more than 90% of these hospitals based in the United States. The primary goal of the current study was to determine the proportion of hip fracture patients admitted to ACS-NSQIP hospitals who have been treated within the NICE time-to-surgery benchmark. The secondary goals were to identify factors associated with missing the NICE benchmark and to determine whether meeting the benchmark was associated with reductions in patient mortality, complications, and length of stay (LOS).

Materials and Methods

Data Collection and Patient Selection

A retrospective cohort study was conducted using the prospective ACS-NSQIP database to identify patients who underwent hip fracture surgery between January 1, 2005, and December 31, 2013. Current Procedural Terminology (CPT) codes 27245 (intramedullary implant), 27244 (plate/screw fixation), 27236 (open reduction), and 27235 (percutaneous fixation) were used to identify patients undergoing closed and open hip fracture fixation. Patients who underwent hemiarthroplasty (CPT code 27125) or total hip arthroplasty (CPT code 27130) for a diagnosis of hip fracture (International Classification of Diseases, Ninth Revision [ICD-9] codes 820.x) were also included in the study. Patients with hip fractures who were younger than 60 years at the time of admission and those with missing time to surgery, CPT code, and ICD-9 code data if undergoing arthroplasty were excluded from the study. For the secondary multivariate regression analysis, patients with missing data for variables of interest were excluded.

Patient, Demographic, and Perioperative Variables

The ACS-NSQIP reports on a variety of preoperative, comorbidity, demographic, operative, and laboratory variables.32,33 Time to hip fracture surgery, age, sex, and race were extracted. Patients with race other than white or black were grouped as a separate other category. Comorbidity data collected included acute kidney insufficiency (AKI), dyspnea, and infectious illness at time of hospital admission, and functional health status. Body mass index (BMI) was calculated from height and weight. Preoperative international normalized ratio (INR) and admission hematocrit were extracted. American Society of Anesthesiologists (ASA) score, anesthetic technique (general vs other), wound class, and procedure type were extracted. Procedure type was categorized as arthroplasty vs closed or open hip fracture fixation. Mortality was defined as death within 30 days of hip fracture surgery. Length of stay was defined as time in days from surgery to hospital discharge. Thirty-day postoperative complications were divided into major and minor based on precedent in the literature.9 Minor complications were defined as the presence of at least 1 of the following: superficial surgical-site infection (SSI), urinary tract infection (UTI), AKI, deep venous thrombosis (DVT), or pneumonia. Major complications were other clinically relevant complications as defined by the ACS-NSQIP, excluding mortality. These included deep wound infection, sepsis, septic shock, wound dehiscence, pulmonary embolism, unplanned intubation, ventilator use for more than 48 hours, cardiac arrest requiring cardiopulmonary resuscitation, acute myocardial infarction, acute renal failure, cerebrovascular accident, and hardware failure. Detailed definitions of each complication are available in the ACS-NSQIP user guide.33

Statistical Analyses

Statistical analyses were conducted using SAS 9.3 statistical software (SAS Institute Inc, Cary, North Carolina). For the primary outcome, the number of patients who underwent surgery within the NICE guideline (surgery on the day of admission or on post-admission day 1) was summarized with counts and proportions. Relevant demographic and clinical characteristics were compared between patients who were treated within the guideline vs those who were not. Chi-square test was used to compare categorical variables, and t test or Wilcoxon rank sum test was used to compare continuous variables. A P value less than .05 was considered significant.

Multivariate logistic regression analysis was used to examine associations between patients being treated beyond the NICE time-to-surgery benchmark and patient demographics or clinical characteristics. The initial multivariate model contained all but 6 variables, which had over 50% missing values. Variables with insignificant associations were removed from the final model. Other variables that were under a threshold of P<.10 were kept in the final model.

Multivariate linear regression analysis was conducted to examine the association of meeting the NICE time-to-surgery benchmark with LOS, adjusting for other variables that were associated with LOS. Similarly, multivariate logistic regression analysis was used to examine the association of meeting the NICE time-to-surgery benchmark with 30-day mortality, major complications, and minor complications, adjusting for other variables associated with the corresponding outcome.

Results

Patient and Operative Characteristics

A total of 27,937 patients undergoing hip fracture surgery between 2005 and 2013 were identified from the ACS-NSQIP database. After excluding patients younger than 60 years at the time of injury and those missing time-to-surgery data, 26,066 patients were included in the final analysis (Figure). Table 1 compares patient and operative characteristics between the groups. Patients included in the sample were most commonly 80 to 89 years old (n=11,436; 43.9%) and female (n=18,707; 71.8%). Nearly two-thirds (n=16,396; 63.0%) of the patients were categorized with an ASA score of III. The majority of patients were treated with internal fixation (n=20,293; 77.8%), whereas 22.2% (n=5773) underwent arthroplasty.


Consolidated Standards of Reporting Trials (CONSORT) diagram outlining patient selection.

Figure:

Consolidated Standards of Reporting Trials (CONSORT) diagram outlining patient selection.


Patient Demographics, Comorbidities, and Operative Factors Reported According to the NICE Time-to-Hip-Fracture-Surgery Benchmarka (N=26,066)

Table 1:

Patient Demographics, Comorbidities, and Operative Factors Reported According to the NICE Time-to-Hip-Fracture-Surgery Benchmark (N=26,066)

Time to Hip Fracture Surgery

Of the 26,066 patients included in the primary analysis, 71.4% (n=18,611) met the NICE time-to-surgery benchmark (Table 2). Patients most commonly underwent surgery on post-admission day 1 (n=12,632; 48.5%). Extending the time-to-surgery benchmark to include post-admission day 2 occurred in 89.4% (n=23,297) of the study sample.


Time to Hip Fracture Surgery, Overall 30-Day Mortality, and Complicationsa (N=26,066)

Table 2:

Time to Hip Fracture Surgery, Overall 30-Day Mortality, and Complications (N=26,066)

Factors Associated With Missing the NICE Time-to-Surgery Benchmark

The multivariate regression analysis found many factors associated with missing the NICE time-to-surgery benchmark (Table 3), including sex; race; obesity (>30.0 kg/m2); dyspnea; infectious illness at time of hospital admission; bleeding disorder; preoperative hematocrit less than 38%; preoperative platelet count less than 50,000 cells/mm3; INR greater than 1.4; ASA score of III, IV, or V; transfusion requirement; arthroplasty procedure; and femoral neck fracture diagnosis (P<.001). Patients with a functional health status of “totally dependent” (P=.017), overweight patients (25.0–30.0 kg/m2; P=.010), and patients receiving anesthesia other than general (P=.004) were also likely to miss the NICE time-to-surgery benchmark.


Predictors of Missing the NICE Time-to-Hip-Fracture-Surgery Benchmarka (n=22,809)
Predictors of Missing the NICE Time-to-Hip-Fracture-Surgery Benchmarka (n=22,809)

Table 3:

Predictors of Missing the NICE Time-to-Hip-Fracture-Surgery Benchmark (n=22,809)

Outcomes

The 30-day cumulative incidence of mortality was 6.9%. The 30-day cumulative incidence of total, major, and minor complications was 15.8%, 6.7%, and 11.7%, respectively (Table 2). Median postoperative LOS was 4 days (interquartile range, 3–6) for all patients.

When adjusting for multiple relevant variables (Table 4), patients treated within the NICE time-to-surgery benchmark had a statistically significantly shorter postoperative LOS (beta=−0.77; P<.001). Meeting the NICE benchmark was not associated with a reduction in major complications (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83–1.05; P=.234). However, patients who met the benchmark had a lower likelihood of mortality (OR, 0.88; 95% CI, 0.78–0.99; P=.028) and minor complications (OR, 0.92; 95% CI, 0.84–0.995; P=.038).


Multivariate Regression Analysis on the Effect of Time of Hip Fracture Surgery on 30-Day Postoperative Patient Outcomesa

Table 4:

Multivariate Regression Analysis on the Effect of Time of Hip Fracture Surgery on 30-Day Postoperative Patient Outcomes

Extending the time-to-surgery benchmark to post-admission day 2 did not significantly increase the risk of mortality (OR, 0.84; 95% CI, 0.72–0.98; P=.028) and minor complications (OR, 0.81; 95% CI, 0.73–0.91; P<.001). Similar to the NICE benchmark, surgical treatment within the extended benchmark did not significantly reduce the risk of a major complications (OR, 0.89; 95% CI, 0.76–1.04; P=.134). Patients treated after post-admission day 2 had a clinically and statistically significant LOS increase of 1.45 days (P<.001).

Discussion

This study found that more than two-thirds of patients with hip fractures at participating ACS-NSQIP hospitals were treated within the NICE time-to-surgery benchmark, and extending the benchmark to include patients treated on post-admission day 2 would include 89% of the study sample. Many variables, including sex, race, procedure type, and comorbidity, were predictors of missing the benchmark. Meeting the benchmark was not associated with reducing the risk of major complications; however, it was associated with decreased likelihood of 30-day mortality and minor complications.

The finding that 71.4% of patients met the NICE benchmark is consistent with US time-to-surgery data from the ACS National Trauma Data Bank (59%) and National Inpatient Sample (NIS) (72.1%).4,5 Current UK data show that 71.7% of patients meet the NICE benchmark.6 The comparison confirms the feasibility of implementing a similar time-to-surgery benchmark in participating ACS-NSQIP hospitals.

Operating room availability and preoperative medical clearance are the main reported barriers to early surgery, and both are potentially modifiable.8,9 The association between missing the NICE benchmark and nonmodifiable variables such as active infection was not surprising. The study's results identified treatment with arthroplasty as a significant predictor of delay. There are several possible causes for this finding, but because this is a potentially modifiable cause of surgical delay, further investigations to address this association are warranted. In addition, patients who were black and other (including Hispanic) were more likely to miss the benchmark compared with their white counterparts. This was similarly identified in a recent NIS study analyzing more than 2 million patients,5 underscoring potential inequity challenges that the PPACA aims to overcome. The current study's results also support the recent finding that irreversible novel oral anticoagulants are a barrier to timely surgery.24

The reduction in 30-day mortality with timely surgery for a hip fracture is consistent with 2010 and 2012 meta-analyses of adjusted prospective studies.12,13 Nyholm et al26 reported that a delay of more than 12, 24, and 48 hours increased the risk of 30-day mortality; however, only a delay of more than 24 hours increased the risk of 90-day mortality. The United Kingdom reported a 15% decrease in 30-day mortality from 9.2% in 2008 to 8.2% in 2013,6 as have recent UK and US studies at multiple time points.5,14,15 However, it should be noted that several high-quality studies, including a systematic review involving 291,143 patients, did not find a reduction in mortality with early surgical treatment.4,8,9,16–18,25

Meeting the NICE benchmark was associated with a reduction in postoperative LOS, although at less than 1 day, it is of arguable clinical benefit. The current study's findings are in contrast to the clinically significant reductions in postoperative LOS found in current UK data6 and the majority of the literature.18,19,25 This is an important finding given the financial implications of additional postoperative hospital days.

Although inconsistent and limited, the current literature supports early hip fracture surgery to reduce complications.4,5,8,9,12,13,16,20,21,22,25 Morbidity has not been studied as thoroughly as mortality, and many previous studies failed to adequately control for confounders, primarily comorbidity and fracture type.12,13 The current study's adjusted analysis demonstrated no significant difference in major complications between time-to-surgery cohorts. However, the findings identified that early surgery was associated with fewer minor complications.

This study has several limitations. The ACS-NSQIP records time to surgery in days from admission, preventing more precise hourly time-to-surgery analysis. Although the ACS-NSQIP is a high-quality prospective database, the current study was subject to limitations associated with database studies, including incorrect data entry, absence of prognostic variables such as patient insurance status, short-term follow-up, and missing data. However, this large, risk-adjusted, prospectively collected database study may provide the highest possible level of evidence given ethical issues with randomizing the time to treatment in this patient population.26

Despite these limitations, the authors believe this study is a valuable contribution to the hip fracture literature. Although there is support for a time-to-hip-fracture-surgery benchmark in the United States, the authors sought to determine how frequently ACS-NSQIP hospitals—more than 90% of which are located in the United States—meet such a benchmark to better understand the feasibility of implementing a timing standard. They identified several important factors associated with missing the NICE time-to-surgery benchmark that will need to be considered when implementing and enforcing a time-to-surgery standard in participating ACS-NSQIP hospitals. They controlled for confounding factors, including patient comorbidity and procedure type, which is a limitation of many previous studies. Furthermore, the ACS-NSQIP database contains data on functional impairment, type of anesthesia used, laboratory values, and actual diagnosis of comorbidities, which is a limitation of the Danish Fracture Database study.26 To the authors' knowledge, the current study was among the first and largest studies to consider so many clinically important variables. Finally, the study's findings suggest that the current NICE benchmark may be unnecessarily narrow in terms of mortality, minor complications, LOS benefit, and risk of major complications. This should be interpreted with caution given recent studies suggesting that early surgery at less than 12 or 24 hours may further reduce 30-day mortality and morbidity.5,15,26

Conclusion

This study's findings highlight the feasibility and benefit of implementing a time-to-surgery benchmark in the United States. However, the current NICE benchmark may be unnecessarily narrow. Extending the benchmark to post-admission day 2 did not significantly alter the decreased likelihood of 30-day mortality or minor complications, nor did it increase the likelihood of major complications. Many factors were associated with surgical delay, underscoring important time-to-surgery barriers and health care disparities that warrant future investigation for benchmarks to be successfully implemented.

References

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  16. Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma. 2014; 28(2):63–69. doi:10.1097/BOT.0b013e3182a22744 [CrossRef]
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  23. Moran CG, Boultan C, Johansen A, et al. Improving care for older patients with hip fracture. Paper presented at the Orthopaedic Trauma Association 2014 Annual Meeting. ; October 15–18, 2014. ; Tampa, Florida. .
  24. Buse GL, Bhandari M, Sancheti P, et al. Hip Fracture Accelerated Surgical Treatment and Care Track (HIP ATTACK) Investigators. Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial. CMAJ. 2014; 186(1):E52–E60. doi:10.1503/cmaj.130901 [CrossRef]
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  26. Nyholm AM, Gromov K, Palm H, et al. Time to surgery is associated with thirty-day and ninety-day mortality after proximal femoral fracture: a retrospective observational study on prospectively collected data from the Danish fracture database collaborators. J Bone Joint Surg Am. 2015; 97(16):1333–1339. doi:10.2106/JBJS.O.00029 [CrossRef]
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  30. Patient Protection and Affordable Care Act, 42 USC §18001 (2010).
  31. Centers for Medicare and Medicaid Services, Research Triangle Institute. CMS national dry run: all-cause unplanned readmission measure for 30 days post discharge from long-term care hospitals. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/Downloads/LTCH-SODF-Presentation-CMS-National-Dry-Run-October-8-2015-edit-11-15.pdf. Accessed October 20, 2015.
  32. American College of Surgeons. ACS NSQ-IP: data collection, analysis, and reporting. https://www.facs.org/quality-programs/acs-nsqip/program-specifics/data. Accessed December 15, 2014.
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Patient Demographics, Comorbidities, and Operative Factors Reported According to the NICE Time-to-Hip-Fracture-Surgery Benchmarka (N=26,066)

CharacteristicNo. (%)P

Day 0, 1Day ≥2All Patients
Age.057
  60–69 y2184 (11.7)816 (11.0)3000 (11.5)
  70–79 y3976 (21.4)1596 (21.4)5572 (21.4)
  80–89 y8081 (43.4)3355 (45.0)11,436 (43.9)
  90+ y4370 (23.5)1688 (22.6)6058 (23.2)
Sex<.001
  Male4958 (26.7)2388 (32.0)7346 (28.2)
  Female13,641 (73.3)5066 (68.0)18,707 (71.8)
Race/ethnicity<.001
  White14,697 (79.2)5155 (69.3)19,852 (76.4)
  Black474 (2.6)301 (4.1)775 (3.0)
  Other3375 (18.2)1979 (26.6)5354 (20.6)
Body mass index.019
  Underweight (<18.5 kg/m2)1571 (9.6)610 (9.4)2181 (9.5)
  Normal (18.5–25.0 kg/m2)8072 (49.0)3058 (47.3)11,130 (48.5)
  Overweight (25.0–30.0 g/m2)4543 (27.6)1818 (28.1)6361 (27.8)
  Obese (>30.0 kg/m2)2269 (13.8)983 (15.2)3252 (14.2)
Infectious illness<.001
  Yes204 (1.1)204 (2.7)408 (1.6)
  No18,407 (98.9)7251 (97.3)25,658 (98.4)
Preoperative hematocrit<.001
  <38%12,566 (67.5)5920 (79.4)18,486 (70.9)
  ≥38%6045 (32.5)1535 (20.6)7580 (29.1)
INR<.001
  ≤1.417,467 (93.8)6615 (88.7)24,082 (92.4)
  >1.41144 (6.2)840 (11.3)1984 (7.6)
ASA score<.001
  I165 (0.9)24 (0.3)189 (0.7)
  II3814 (20.5)762 (10.2)4576 (17.6)
  III11,811 (63.6)4585 (61.6)16,396 (63.0)
  IV2795 (15.0)2077 (27.9)4872 (18.7)
Procedure type<.001
  Closed or open hip fracture fixation14,868 (79.9)5425 (72.8)20,293 (77.8)
  Total or hemiarthroplasty3743 (20.1)2030 (27.2)5773 (22.2)

Time to Hip Fracture Surgery, Overall 30-Day Mortality, and Complicationsa (N=26,066)

Outcome VariableNo. (%)
NICE time-to-surgery benchmarkb
  Surgery within benchmark18,611 (71.4)
  Surgery outside of benchmark7455 (28.6)
Surgery by post-admission day 2
  0–2 d23,297 (89.4)
  ≥3 d2769 (10.6)
Post-admission time to surgery
  0 d5979 (22.9)
  1 d12,632 (48.5)
  2 d4686 (18.0)
  3 d1428 (5.5)
  ≥4 d1341 (5.1)
Mortality1790 (6.9)
Complications
  Total4124 (15.8)
  Major1750 (6.7)
  Minor3052 (11.7)

Predictors of Missing the NICE Time-to-Hip-Fracture-Surgery Benchmarka (n=22,809)

VariableOR (95% CI)P
Age
  60–69 yReference
  70–79 y0.96 (0.85–1.07).419
  80–89 y0.94 (0.85–1.04).238
  90+ y0.87 (0.77–0.97).014
Sex
  MaleReference
  Female0.86 (0.80–0.92)<.001
Race/ethnicity
  WhiteReference
  Black1.53 (1.30–1.80)<.001
  Other1.8 (1.66–1.96)<.001
Functional health status
  IndependentReference
  Partially dependent1.04 (0.97–1.12).280
  Totally dependent1.18 (1.03–1.36).017
  Unknown0.79 (0.58–1.08).135
Body mass index
  Underweight (<18.5 kg/m2)Reference
  Normal (18.5–25.0 kg/m2)1.05 (0.95–1.17).351
  Overweight (25.0–30.0 kg/m2)1.17 (1.04–1.31).010
  Obese (>30.0 kg/m2)1.28 (1.12–1.45)<.001
Acute renal failure
  Yes1.37 (0.96–1.95).079
Dyspnea
  Yes1.29 (1.17–1.43)<.001
Infectious illness
  Yes2.11 (1.69–2.63)<.001
Bleeding disorder
  Yes1.6 (1.47–1.73)<.001
Preoperative hematocrit
  <38%Reference
  ≥38%0.57 (0.53–0.61)<.001
Preoperative platelet count
  ≥50 cells/mm3Reference
  <50 cells/mm31.86 (1.38–2.5)<.001
INR
  ≤1.4Reference
  >1.41.25 (1.11–1.40)<.001
ASA score
  IReference
  II1.34 (0.82–2.17).239
  III2.29 (1.42–3.69)<.001
  IV and V3.76 (2.32–6.09)<.001
Anesthesia
  GeneralReference
  Spinal, epidural, or all other not general1.11 (1.03–1.19).004
Transfusion
  Yes3.36 (2.97–3.8)<.001
Procedure type
  Open or percutaneous fixationReference
  Arthroplasty1.55 (1.43–1.68)<.001
Hip fracture diagnosis
  Femoral neck fractureReference
  Peri-/inter-/subtrochanteric fracture0.83 (0.77–0.89)<.001

Multivariate Regression Analysis on the Effect of Time of Hip Fracture Surgery on 30-Day Postoperative Patient Outcomesa

Time VariableLOS (n=22,791)Mortality (n=22,806)Complications



BetaPOR (95% CI)PMajor (n=22,809) OR (95% CI)PMinor (n=25,941) OR (95% CI)P
NICE time-to-surgery benchmarkb
  Day 0, 1−0.77<.0010.88 (0.78–0.99).0280.93 (0.83–1.05).2340.92 (0.84–0.995).038
  Day ≥2Reference-Reference-Reference-Reference-
Extended time-to-surgery benchmarkc
  Day 0–2−1.45<.0010.84 (0.72–0.98).0280.89 (0.76–1.04).1340.81 (0.73–0.91)<.001
  Day ≥3Reference-Reference-Reference-Reference-
Authors

The authors are from the Department of Orthopaedics (MEN, HMB, KAL) and the Department of Statistics (YZ), University of British Columbia, Vancouver, British Columbia, Canada; and the Department of Orthopaedics (NNO, JMA, GPS) and the Department of Epidemiology & Public Health (MZ), University of Maryland School of Medicine, Baltimore, Maryland.

The authors have no relevant financial relationships to disclose.

This study was supported by a grant from the MITRE Corporation.

Correspondence should be addressed to: Gerard P. Slobogean, MD, MPH, FRCSC, Department of Orthopaedics, University of Maryland School of Medicine, Ste 300, 110 S Paca St, Baltimore, MD 21201 ( gslobogean@umoa.umm.edu).

Received: February 18, 2016
Accepted: June 01, 2016
Posted Online: July 27, 2016

10.3928/01477447-20160719-07

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