Orthopedics

Feature Article 

Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients

Brendan Y. Shi, MD; Casey V. Hannan, BS; Jessica M. Jang, BS; Iman Ali, BS; Uma Srikumaran, MD, MBA, MPH

Abstract

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is “surgery delay” (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609–e615.]

Abstract

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is “surgery delay” (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609–e615.]

Hip fracture is one of the most common injuries among the elderly, with approximately 340,000 cases annually nationwide, costing an estimated $12 billion.1,2 Hip fractures are associated with mortality rates of approximately 9% at 30 days3,4 and 21% to 33% at 1 year3,5; even after surgical fixation, hip fractures are associated with major loss of function, impaired independence, high rates of nursing home care, and financial burden.6–8 Improving the care of patients with hip fractures can improve patient outcomes and reduce health care costs.9–12

The appropriate waiting time for hip fracture surgery (surgery delay) has been debated. Although current guidelines from the American Academy of Orthopaedic Surgeons13 recommended surgery within 48 hours of presentation to the emergency department (ED), recent studies by Pincus et al14 and Fu et al15 suggested that delaying surgery for greater than 24 hours after presentation may result in higher complication rates, higher 30-day mortality rates, and longer hospital stays.14,15 In addition, Fu et al15 found that greater than 75% of surgeries for hip fracture nationwide are delayed for greater than 24 hours, suggesting that major changes are needed to meet the 24-hour threshold. Reasons for surgery delay include medical clearance, operating room availability, and the need to stabilize patient comorbidities15,16; however, ED efficiency and time to radiographic evaluation may represent modifiable variables to reduce surgery delay.17,18

Many European nations have introduced multidisciplinary streamed-care pathways in which the ED staff work with radiology, orthopedic, cardiology, and geriatric medicine staff to streamline care. Streamed-care pathways are associated with shorter hospital stays, reduced surgery delay, and better outcomes after hip fracture9–12,19 and are cost-effective in hospitals with at least moderate volume.20 These studies also suggest that, given the substantial physical, mental, and economic costs of hip fractures, mortality rates alone may be too narrow a metric for evaluating outcomes. The associations between surgery delay and functional outcomes in patients with hip fractures are unclear.

In this study, the authors sought to identify predictors of surgery delay in patients with hip fractures and to quantify the relationship between surgery delay and postoperative opioid demand given the significant association between pain and functional impairment.21 They asked: (1) Do patients who receive earlier radio-graphic evaluation of hip fracture undergo surgery earlier? and (2) Is surgery delay associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? They hypothesized that patients who received earlier radiographic evaluation would undergo surgery earlier, and that those who underwent surgery within 24 hours would have shorter hospital stays, require less pain medication, and have lower mortality rates at 30 days and 1 year postoperatively.

Materials and Methods

Patient Population

With approval and waiver of consent from their institutional review board, the authors obtained patient information from their institution's electronic health records. All patients 60 years and older who were admitted to the ED from January 1, 2015, to December 31, 2017, and who underwent surgical fixation of a hip fracture were identified using International Classification of Diseases, Tenth Revision, diagnosis codes for hip fracture.

A total of 513 consecutive patients met these criteria, 2 of whom were excluded for history of surgery on the same hip, leaving 511 patients (362 women) for analysis (Table 1). Mean±SD patient age was 82±9.1 years, and mean±SD body mass index (BMI) was 24±5.2 kg/m2. Mean±SD Charlson Comorbidity Index (CCI) score was 5.5±1.8. Half of the patients were treated with cephalomedullary nailing (n=255), and the remaining patients were treated with hemiarthroplasty (n=168), closed reduction and percutaneous pinning (n=62), open reduction and internal fixation via placement of dynamic/sliding hip screw (n=16), or total hip arthroplasty (n=10).

Characteristics and Outcomes of 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center from 2015 to 2017, by Time to Surgery

Table 1:

Characteristics and Outcomes of 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center from 2015 to 2017, by Time to Surgery

Radiography and Surgery Delays

Patients were categorized as having experienced radiography delay (time from presentation to first hip radiograph) that was short (≤2 hours), medium (>2 to 4 hours), or long (>4 hours). Because previous studies have recommended surgery delay ranging from 12 to 48 hours,13,14,22–25 the authors categorized patients as having experienced surgery delay of 12 hours or less, greater than 12 to 24 hours, greater than 24 to 36 hours, greater than 36 to 48 hours, greater than 48 to 60 hours, or greater than 60 hours.

Outcomes

The authors obtained data on the following patient outcomes from electronic health records: morphine equivalent consumption during the first 24 hours postoperatively, duration of hospital stay, 30-day mortality, and 1-year mortality. Mortality data were first collected by querying the electronic health records to assess whether patients were alive at 30 days and 1 year postoperatively. For patients whose survival status could not be determined by using their electronic health records, mortality data were obtained by querying their names in online search engines for publicly available obituary records, as previously described.26

Statistical Analysis

Frequency histograms and Shapiro–Wilk tests were used to confirm parametric distribution of data. For unadjusted analyses, the authors compared outcomes by time-based cohorts using analysis of variance, Student's t tests, and chi-square tests. Adjusted analyses with logistic and multivariate linear regressions were subsequently performed, controlling for gender, age, BMI, CCI score, day of the week of hospital admission, and procedure type. Ordered logistic regressions were used for nonparametric dependent variables.

Post hoc adjusted analysis was performed to control for the effect of higher CCI score in cohorts that experienced longer surgery delay. A CCI score greater than 6 is known to be an independent predictor of 30-day mortality after hip fractures.27 The authors stratified patients into 2 cohorts: those with CCI scores of 6 or less (n=378) and those with CCI scores greater than 6 (n=133).

All statistical tests were conducted with Stata version 15 software (StataCorp, College Station, Texas). P<.05 was considered statistically significant.

Results

Radiography Delay

Mean±SD radiography delay was 1.8±3.0 hours. Most patients (n=476; 93%) experienced short or medium radiography delay. Of those 476 patients, 396 (83%) experienced short radiography delay. The authors found no significant differences in age, sex distribution, BMI, or CCI scores between patients in different radiography delay groups (Table 2). No association was found between weekday of admission and radiography delay.

Characteristics and Outcomes of 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center From 2015 to 2017, by Radiography Delay

Table 2:

Characteristics and Outcomes of 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center From 2015 to 2017, by Radiography Delay

Patients who experienced short radiography delay underwent surgery significantly earlier (mean±SD, 36±34 hours) than patients who experienced medium radiography delay (mean±SD, 48±81 hours; P=.031; Table 2). After adjusting for age, sex, BMI, CCI score, and procedure type, radiography delay was found to be a significant predictor of surgery delay; patients who experienced medium radiography delay underwent surgery 11 hours (95% confidence interval [CI], 1.4 to 20) later than those who experienced short radiography delay (Table 3). The authors found no significant associations between radiography delay and opioid use, duration of hospital stay, or mortality rates.

Predictors of Surgery Delay in 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center From 2015 to 2017

Table 3:

Predictors of Surgery Delay in 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center From 2015 to 2017

Surgery Delay

Mean±SD surgery delay was 38±45 hours. Most patients (n=410; 80%) had surgery delay of 48 hours or less,13 and 26 (5%) had surgery delay of 12 hours or less. When comparing patients across the 6 surgery delay categories, the authors found no significant differences in BMI, age, or sex distribution. However, patients who had longer surgery delay had worse CCI scores and were more likely to have undergone total hip arthroplasty (Table 1).

The variables significantly associated with surgery delay were longer radiography delay, older age, and treatment with total hip arthroplasty (beta, 67.3 hours; 95% CI, 40.0 to 94.7; Table 3). Weekday of admission was not significantly associated with surgery delay.

Opioid Consumption

Mean±SD overall 24-hour postoperative opioid consumption was 16±17 morphine equivalents. Patients who experienced 12 hours or less of surgery delay consumed significantly fewer mean±SD morphine equivalents (11±8) than did patients who had greater than 12 to 24 hours of surgery delay (19±20; P=.046). Adjusted analysis confirmed these findings: surgery delay of greater than 12 hours was associated with consumption of a mean 9.6 additional morphine equivalents (95% CI, 0.7 to 8.6) during the first 24 hours postoperatively. The authors found no other significant associations between surgery delay and opioid consumption.

Duration of Hospital Stay

Mean±SD duration of hospital stay was 145±96 hours (approximately 6 days). Un-adjusted regression showed a significant positive correlation between surgery delay and duration of hospital stay (beta, 1.5; P<.001), with each 1-hour increase in surgery delay corresponding to an additional 1.5 hours of hospital stay. Adjusted analysis confirmed that surgery delay of greater than 36 hours (odds ratio, 2.8; 95% CI, 1.7 to 4.8) and a higher CCI score (odds ratio, 1.2; 95% CI, 1.0 to 1.3) were independent risk factors for longer hospital stay. Age, sex, BMI, and procedure type were not significantly associated with duration of hospital stay.

Mortality Rates

Mean 30-day and 1-year mortality rates for all patients were 3.5% and 15%, respectively. The 30-day mortality rate was significantly higher in patients who experienced greater than 36 hours of surgery delay (6.4%) compared with patients who experienced 36 hours or less of surgery delay (2.1%; P=.01). Similarly, the 1-year mortality rate was significantly higher in patients who experienced greater than 36 hours of surgery delay (23%) compared with patients who experienced 36 hours or less of surgery delay (12%; P=.001). Otherwise, the authors found no significant associations between surgery delay and 30-day or 1-year mortality rate.

Adjusted analysis confirmed these relationships. Among patients with CCI scores of 6 or less, those who had surgery delay of greater than 36 to 48 hours had 13.5 times greater odds (95% CI, 1.2 to 148) of dying within 30 days than those who had surgery delay of greater than 24 to 36 hours. Furthermore, among patients with CCI scores of 6 or less, those who had surgery delay of greater than 36 to 48 hours had 4.6 times greater odds (95% CI, 1.5 to 14) of dying within 1 year than those who had surgery delay of greater than 24 to 36 hours. The authors found no significant association between CCI score and mortality rate at 30 days or 1 year, nor between mortality rates and age, sex, BMI, or procedure type.

Discussion

In this single-center retrospective study of 511 elderly patients who underwent surgery for hip fracture, 20% of patients experienced more than the recommended 48 hours of surgery delay. Prompt radiographic evaluation in the ED (within 2 hours) was associated with an 11-hour shorter surgery delay. Surgery delay of 12 hours or less was associated with less postoperative opioid use than surgery delay of greater than 12 to 24 hours. Finally, patients who experienced 36 hours or less of surgery delay had lower mortality rates and shorter hospital stays compared with those who experienced greater than 36 hours of surgery delay.

Although many studies have examined relationships between surgery delay and outcomes after hip fracture,4,14–16,22,28 the current authors believe that their findings have several important implications. First, these results suggest that ED efficiency (as measured by radiography delay) is associated with shorter surgery delay, even when controlling for known predictors, such as procedure type, day of week, and patient factors.29–32 Two additional hours of radiography delay may not affect surgery delay because patients with hip fracture are typically scheduled for next-day surgery, but the current authors hypothesize that patients who receive earlier radiographic evaluation may also be evaluated earlier by ancillary services needed for surgical clearance and may be scheduled for surgery earlier in the day. Studies evaluating hospitals with multidisciplinary streamed-care pathways have shown that efficient triage and management of patients with hip fractures significantly reduces surgery delay.5,11,33–35 These streamed-care pathways, which involve prompt radiographic and orthopedic evaluation, early coordination with geriatric medicine specialists, and preoperative risk assessments by anesthesiologists in the ED,9,33 have also been associated with fewer complications12,36 and shorter hospital stays.12,34,37

Second, the current authors found that earlier surgery is associated with decreased postoperative opioid consumption. Despite evidence that patients with lower pain scores after hip fracture have better physical therapy adherence, faster recovery of ambulation, and lower rates of functional impairment,21 few studies have examined the association between surgery delay and postoperative pain. Orosz et al16 found that patients who underwent surgery within 24 hours reported lower mean pain scores during the first 5 postoperative days compared with those who underwent surgery later,21 but their results were limited by heterogeneity (included 4 hospitals). By using an objective surrogate for pain, the current study reinforces the idea that prompt surgical treatment (here, within 12 hours) may minimize postoperative pain. Only 5% of the current patients received surgery within this time frame; hence, this represents a major opportunity to improve patient care.

Finally, the current results add to the growing evidence that hospitals should work toward surgery delays shorter than the 48 hours recommended by the American Academy of Orthopaedic Surgeons.16,28,38 The United Kingdom's Royal College of Physicians recommends surgery within 36 hours.39 The robust study of more than 42,000 elderly patients by Pincus et al14 found substantial evidence supporting the benefits of surgery within 24 hours. Bretherton and Parker22 advocated even earlier surgery, reporting a 30-day mortality rate of 6.1% among patients who experienced 13 to 18 hours of surgery delay compared with a mortality rate of 3.8% for patients who experienced 7 to 12 hours of surgery delay. Research on the duration of hospital stay is similar. Studies by Mitchell et al40 and Orosz et al16 found that surgery within 24 hours was associated with 1- to 2-day shorter hospital stays compared with longer surgery delays. The current findings and those of recent studies suggest that surgical treatment of hip fractures within 48 hours of presentation may reduce the duration of hospital stays and the risk of death.

Limitations

This study had limitations associated with its retrospective design. First, although the study accounted for many factors that may influence time to surgery, the authors were unable to include variables such as patient census (number of patients in the ED) and operating room availability. However, if ED patient occupancy was indeed correlated with time to hip imaging, then these 2 collinear independent variables would not have been included in the same regression. Moreover, although operating room availability may influence surgery delay, it is unlikely to affect ED efficiency and thus is unlikely to be a confounding variable in the current analysis.

Second, the delay categories do not account for time from injury to patient arrival at the hospital. Third, the authors did not assess the association of patient anticoagulation status with surgery delay. However, it is unlikely that anticoagulation status is associated with radiography delay. Fourth, the authors used objective data as their outcome variables (duration of hospital stay, units of morphine equivalents used, and death) and did not assess patient-reported outcomes. Fifth, because most patient characteristics did not differ significantly across delay cohorts, the authors did not perform propensity score matching. Although patients in longer-delay groups had higher CCI values and a larger proportion of total hip arthroplasties, the authors believe that they adequately accounted for these differences while preserving statistical power through stratification and multivariate regression. Finally, this was a single-site study with statistical power limited by the size of the authors' catchment area and patient population. However, heterogeneity is decreased because of the single-site design.

Conclusion

Early radiographic evaluation was associated with earlier surgical fixation of hip fractures. Surgery delay of 12 hours or less was associated with less opioid use, and surgery delay of 36 hours or less was associated with lower 30-day and 1-year mortality rates, as well as shorter hospital stays.

References

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Characteristics and Outcomes of 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center from 2015 to 2017, by Time to Surgery

VariableTime to Surgery, h

≤12>12 to 24>24 to 36>36 to 48>48 to 60>60Overall

No. (%)Mean±SDNo. (%)Mean±SDNo. (%)Mean±SDNo. (%)Mean±SDNo. (%)Mean±SDNo. (%)Mean±SDNo. (%)Mean±SD
Patients26 (5.1)142 (33)172 (66)69 (80)55 (91)47 (100)511
Female sex19 (73)104 (73)125 (73)47 (68)33 (60)34 (72)362 (71)
Age, y83±7.682±9.582±9.085±9.183±8.383±9.982±9.1
BMI, kg/m225±6.424±5.224±5.024±4.824±4.724±6.024±5.2
CCI score5.6±1.95.3±1.75.1±1.85.9±1.95.7±1.76.1±1.75.5±1.8
THA0 (0.0)1 (0.7)1 (0.5)1 (1.4)4 (7.3)3 (6.4)10 (2.0)
Time to first hip radiograph, h1.2±0.71.8±2.61.7±3.02.1±4.51.7±1.12.3±3.81.8±3.0
Pain medication (ME)a11±819±2014±1315±1719±2217±1816±17
LOS, h122±52124±85122±46154±71162±56267±199145±96
Mortality
  30-day1 (3.8)4 (2.8)2 (1.2)4 (5.8)0 (0)7 (15)18 (3.5)
  1-year3 (12)18 (13)18 (10)16 (23)9 (16)14 (30)78 (15)

Characteristics and Outcomes of 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center From 2015 to 2017, by Radiography Delay

VariableRadiography Delay, h

2>2 to 4>4

No. (%)Mean±SDNo. (%)Mean±SDNo. (%)Mean±SD
Patients396 (77)80 (93)35 (100)
Female sex281 (71)59 (74)22 (63)
Age, y83±8.882±1079±9.9
BMI, kg/m224±5.024±6.324±3.1
CCI score5.5±1.75.5±1.85.4±2.3
Time to surgery, h36±3448±8141±27
Pain medication (ME)a16±1618±2220±22
Mortality
  30-day15 (3.8)2 (2.5)1 (2.9)
  1-year61 (15)10 (13)7 (20)
LOS, h141±81160±155153±59

Predictors of Surgery Delay in 511 Elderly Patients Who Underwent Surgical Hip Fracture Repair at 1 Center From 2015 to 2017

Independent VariableBeta95% CIP
CCI score0.64−1.22 to 2.49.501
Body mass index0.54−0.16 to 1.23.128
Age0.410.04 to 0.78.029
Sex−3.0−9.73 to 3.67.374
Radiography delay, h
  ≤2Referent
  >2 to 410.61.38 to 19.8.024
  >4−0.75−14.7 to 13.3.916
Day of week
  Monday to ThursdayReferent
  Friday−3.28−11.6 to 5.04.439
  Saturday or Sunday−3.92−11.1 to 3.23.282
Procedure
  CRPPReferent
  ORIF0.67−16.9 to 18.2.940
  Cephalomedullary nail0.26−9.99 to 10.5.960
  Hemiarthroplasty5.79−4.72 to 16.3.279
  Total hip arthroplasty67.340.0 to 94.7<.001
Authors

The authors are from the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Dr Shi, Ms Hannan, Ms Jang, and Ms Ali have no relevant financial relationships to disclose. Dr Srikumaran is on the Board of Tigon Medical; is a paid consultant for Conventus, Orthofix, Tigon Medical, Fx Shoulder USA, DePuy/Pacira, Heron, Corin, and Smith & Nephew; has received grants from OMEGA, ASES, Arthrex, DePuy, Wright, and Smith & Nephew; has patents with Tigon Medical, Conventus, and Fx Shoulder USA; and holds stock in Quantum OPS and Tigon Medical.

Correspondence should be addressed to: Uma Srikumaran, MD, MBA, MPH, Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287 ( us@jhmi.edu).

Received: April 02, 2019
Accepted: August 05, 2019
Posted Online: August 20, 2020

10.3928/01477447-20200812-06

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