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 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.
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.
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 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 Benchmark (n=22,809)
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 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).
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
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.
- Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009; 302(14):1573–1579. doi:10.1001/jama.2009.1462 [CrossRef]
- Zuckerman JD. Hip fracture. N Engl J Med. 1996; 334(23):1519–1525. doi:10.1056/NEJM199606063342307 [CrossRef]
- Cooper C, Campion G, Melton LJ III, . Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992; 2(6):285–289. doi:10.1007/BF01623184 [CrossRef]
- Belmont PJ Jr, Garcia EJ, Romano D, Bader JO, Nelson KJ, Schoenfeld AJ. Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank. Arch Orthop Trauma Surg. 2014; 134(5):597–604. doi:10.1007/s00402-014-1959-y [CrossRef]
- Ryan DJ, Yoshihara H, Yoneoka D, Egol KA, Zuckerman JD. Delay in hip fracture surgery: an analysis of patient-specific and hospital-specific risk factors. J Orthop Trauma. 2015; 29(8):343–348. doi:10.1097/BOT.0000000000000313 [CrossRef]
- Royal College of Physicians. Falls and Fragility Fracture Audit Programme (FFFAP): National Hip Fracture Database (NHFD) annual report 2014. http://www.nhfd.co.uk/20/hipfractureR.nsf/vwcontent/2014reportPDFs/$file/NHFD2014ExtendedReport.pdf. Accessed December 15, 2014.
- British Orthopaedic Association, British Geriatrics Society. The National Hip Fracture Database preliminary national report 2009. http://www.nhfd.co.uk/20/hipfractureR.nsf/vwcontent/2009ReportDownload/$File/NHFD2009Report.pdf. Accessed December 15, 2014.
- Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important?J Bone Joint Surg Am. 2005; 87(3):483–489. doi:10.2106/JBJS.D.01796 [CrossRef]
- Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004; 291(14):1738–1743. doi:10.1001/jama.291.14.1738 [CrossRef]
- Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after hip fracture surgery. J Bone Joint Surg Br. 2005; 87(3):361–366. doi:10.1302/0301-620X.87B3.15300 [CrossRef]
- Hartz AJ, Krakauer H, Kuhn EM, et al. Hospital characteristics and mortality rates. N Engl J Med. 1989; 321(25):1720–1725. doi:10.1056/NEJM198912213212506 [CrossRef]
- Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010; 182(15):1609–1616. doi:10.1503/cmaj.092220 [CrossRef]
- Moja L, Piatti A, Pecoraro V, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One. 2012; 7(10):e46175. doi:10.1371/journal.pone.0046175 [CrossRef]
- Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006; 332(7547):947–951. doi:10.1136/bmj.38790.468519.55 [CrossRef]
- Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013; 44(6):726–729. doi:10.1016/j.injury.2012.08.025 [CrossRef]
- 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]
- Rae HC, Harris IA, McEvoy L, Todorova T. Delay to surgery and mortality after hip fracture. ANZ J Surg. 2007; 77(10):889–891. doi:10.1111/j.1445-2197.2007.04267.x [CrossRef]
- Smektala R, Endres HG, Dasch B, et al. The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures. BMC Musculoskelet Dis. 2008; 9:171. doi:10.1186/1471-2474-9-171 [CrossRef]
- Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005; 87(8):1123–1126. doi:10.1302/0301-620X.87B8.16357 [CrossRef]
- Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009; 91(7):922–927. doi:10.1302/0301-620X.91B7.22446 [CrossRef]
- Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995; 77(10):1551–1556.
- Brox WT, Roberts KC, Taksali S, et al. The American Academy of Orthopaedic Surgeons evidence-based guideline on management of hip fractures in the elderly. J Bone Joint Surg Am. 2015; 97(14):1196–1199. doi:10.2106/JBJS.O.00229 [CrossRef]
- 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. .
- 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]
- Khan SK, Kalra SK, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,143 patients. Injury. 2009; 40(7):692–697. doi:10.1016/j.injury.2009.01.010 [CrossRef]
- 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]
- Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011; 155(4):226–233. doi:10.7326/0003-4819-155-4-201108160-00006 [CrossRef]
- Department of Health United Kingdom. Best practice tariff for fragility hip fracture care. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/DH_105080. Accessed February 3, 2015.
- National Institute for Health and Care Excellence. Hip fracture: management. https://www.nice.org.uk/guidance/cg124. Accessed December 15, 2014.
- Patient Protection and Affordable Care Act, 42 USC §18001 (2010).
- 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.
- 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.
- American College of Surgeons National Surgical Quality Improvement Program. User guide for the 2011 participant use data file. https://www.facs.org/~/media/files/quality%20programs/nsqip/ug11.ashx. Accessed December 15, 2014.
Patient Demographics, Comorbidities, and Operative Factors Reported According to the NICE Time-to-Hip-Fracture-Surgery Benchmarka (N=26,066)
|Day 0, 1||Day ≥2||All Patients|
| 60–69 y||2184 (11.7)||816 (11.0)||3000 (11.5)|
| 70–79 y||3976 (21.4)||1596 (21.4)||5572 (21.4)|
| 80–89 y||8081 (43.4)||3355 (45.0)||11,436 (43.9)|
| 90+ y||4370 (23.5)||1688 (22.6)||6058 (23.2)|
| Male||4958 (26.7)||2388 (32.0)||7346 (28.2)|
| Female||13,641 (73.3)||5066 (68.0)||18,707 (71.8)|
| White||14,697 (79.2)||5155 (69.3)||19,852 (76.4)|
| Black||474 (2.6)||301 (4.1)||775 (3.0)|
| Other||3375 (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)|
| Yes||204 (1.1)||204 (2.7)||408 (1.6)|
| No||18,407 (98.9)||7251 (97.3)||25,658 (98.4)|
| <38%||12,566 (67.5)||5920 (79.4)||18,486 (70.9)|
| ≥38%||6045 (32.5)||1535 (20.6)||7580 (29.1)|
| ≤1.4||17,467 (93.8)||6615 (88.7)||24,082 (92.4)|
| >1.4||1144 (6.2)||840 (11.3)||1984 (7.6)|
| I||165 (0.9)||24 (0.3)||189 (0.7)|
| II||3814 (20.5)||762 (10.2)||4576 (17.6)|
| III||11,811 (63.6)||4585 (61.6)||16,396 (63.0)|
| IV||2795 (15.0)||2077 (27.9)||4872 (18.7)|
| Closed or open hip fracture fixation||14,868 (79.9)||5425 (72.8)||20,293 (77.8)|
| Total or hemiarthroplasty||3743 (20.1)||2030 (27.2)||5773 (22.2)|
Time to Hip Fracture Surgery, Overall 30-Day Mortality, and Complicationsa (N=26,066)
|Outcome Variable||No. (%)|
|NICE time-to-surgery benchmarkb|
| Surgery within benchmark||18,611 (71.4)|
| Surgery outside of benchmark||7455 (28.6)|
|Surgery by post-admission day 2|
| 0–2 d||23,297 (89.4)|
| ≥3 d||2769 (10.6)|
|Post-admission time to surgery|
| 0 d||5979 (22.9)|
| 1 d||12,632 (48.5)|
| 2 d||4686 (18.0)|
| 3 d||1428 (5.5)|
| ≥4 d||1341 (5.1)|
| Total||4124 (15.8)|
| Major||1750 (6.7)|
| Minor||3052 (11.7)|
Predictors of Missing the NICE Time-to-Hip-Fracture-Surgery Benchmarka (n=22,809)
|Variable||OR (95% CI)||P|
| 60–69 y||Reference|
| 70–79 y||0.96 (0.85–1.07)||.419|
| 80–89 y||0.94 (0.85–1.04)||.238|
| 90+ y||0.87 (0.77–0.97)||.014|
| Female||0.86 (0.80–0.92)||<.001|
| Black||1.53 (1.30–1.80)||<.001|
| Other||1.8 (1.66–1.96)||<.001|
|Functional health status|
| Partially dependent||1.04 (0.97–1.12)||.280|
| Totally dependent||1.18 (1.03–1.36)||.017|
| Unknown||0.79 (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|
| Yes||1.37 (0.96–1.95)||.079|
| Yes||1.29 (1.17–1.43)||<.001|
| Yes||2.11 (1.69–2.63)||<.001|
| Yes||1.6 (1.47–1.73)||<.001|
| ≥38%||0.57 (0.53–0.61)||<.001|
|Preoperative platelet count|
| ≥50 cells/mm3||Reference|
| <50 cells/mm3||1.86 (1.38–2.5)||<.001|
| >1.4||1.25 (1.11–1.40)||<.001|
| II||1.34 (0.82–2.17)||.239|
| III||2.29 (1.42–3.69)||<.001|
| IV and V||3.76 (2.32–6.09)||<.001|
| Spinal, epidural, or all other not general||1.11 (1.03–1.19)||.004|
| Yes||3.36 (2.97–3.8)||<.001|
| Open or percutaneous fixation||Reference|
| Arthroplasty||1.55 (1.43–1.68)||<.001|
|Hip fracture diagnosis|
| Femoral neck fracture||Reference|
| Peri-/inter-/subtrochanteric fracture||0.83 (0.77–0.89)||<.001|
Multivariate Regression Analysis on the Effect of Time of Hip Fracture Surgery on 30-Day Postoperative Patient Outcomesa
|Time Variable||LOS (n=22,791)||Mortality (n=22,806)||Complications|
|Beta||P||OR (95% CI)||P||Major (n=22,809) OR (95% CI)||P||Minor (n=25,941) OR (95% CI)||P|
|NICE time-to-surgery benchmarkb|
| Day 0, 1||−0.77||<.001||0.88 (0.78–0.99)||.028||0.93 (0.83–1.05)||.234||0.92 (0.84–0.995)||.038|
| Day ≥2||Reference||-||Reference||-||Reference||-||Reference||-|
|Extended time-to-surgery benchmarkc|
| Day 0–2||−1.45||<.001||0.84 (0.72–0.98)||.028||0.89 (0.76–1.04)||.134||0.81 (0.73–0.91)||<.001|
| Day ≥3||Reference||-||Reference||-||Reference||-||Reference||-|