Original Research

Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay

Publish date: September 7, 2018

References

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Recent estimates of the cost of hospital admission is approximated nationally at $2000/day.²⁶ Although our data fail to support the formal cost-analysis of the effect of time-to-surgery in hip fracture care, a simple value-based analysis indicates that quality is preserved (no difference in outcome), whereas costly hospital days are eliminated with earlier surgery. The value in elderly hip fracture care. defined as the outcomes relative to the costs,⁷is ultimately optimized by earlier time-to-surgery.

Although using a large, multi-institutional database is advantageous for finding population-based trends that are representative of a large cohort, using the ACS-NSQIP database features its limitations. Our analysis was limited to the defined scope of NSQIP and nature of the injury, whereas root cause for delay was not available for study. We were unable to identify which patients were delayed for administrative reasons or surgical convenience and which were delayed for medical optimization. Participation in the ACS-NSQIP database is voluntary, and no randomized hospital sampling was conducted. Participating hospitals were de-identified in the database. As expected, we were unable to identify the specific institution-based hip fracture protocols that may affect the outcomes following treatment for these fractures. Further, socioeconomic information and payer-status are unavailable for the study. Additionally, observations are limited to 30 days postoperative, and we cannot comment on longer-term outcomes. Finally, discharge disposition and functional outcome data are not represented, and we were unable to correlate time-to-surgery and functional recovery. However, previous studies have established that delay in time-to-surgery following hip fractures is negatively correlated with functional outcomes.^22-25

Nevertheless, the ACS-NSQIP database remains one of the largest American surgical databases available, and includes care centers from nearly every state with variable demographics including rural, urban, and academic centers. The ACS performs broad-based inter-rater reliability audits on every participating site and has found an overall disagreement rate of only 1.8%. As such, although discrepancies exist between the complete patient chart and the data entered, the data found in the ACS-NSQIP database are reliable and considered a valid source of study.^34,35The large sample size, quality of data collection, wide geographic representation, and varied hospital types within the dataset possibly make our findings relevant in the majority of American healthcare settings.

CONCLUSION

This study demonstrates an associated increased length of hospital stay, including the increased time from surgery-to-discharge, in patients with hip fractures whose surgical intervention is delayed for >48 hours after presentation. Given the prior evidence that early surgical intervention improves the functional outcomes and the current evidence that surgical delay for any cause increases costly hospital length of stay without corollary improvement in the outcomes, a value-based assessment of hip fracture care argues for early surgical intervention whenever possible. Our findings should inform physician, institution, and policy maker value-based decision making regarding the best practices in geriatric hip fracture care.

References

5. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334(23):1519-1525. doi:10.1056/NEJM199606063342307.

6. Marottoli RA, Berkman LF, Cooney LM Jr. Decline in physical function following hip fracture. J Am Geriatr Soc. 1992;40(9):861-866. doi:10.1111/j.1532-5415.1992.tb01980.x.

7. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024.

11. 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.

18. 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.

19. 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.

35. ACS National Surgical Quality Improvement Program. American College of Surgeons Web site. https://www.facs.org/quality-programs/acs-nsqip?. Accessed March 14, 2013.

Time-to-Surgery for Definitive Fixation of Hip Fractures: A Look at Outcomes Based Upon Delay

References

CONCLUSION

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