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

OBJECTIVES Previous observational research has shown that elderly patients with hip fractures who are operated early (within 48 hours from admission) benefit from less short‐ and long‐term mortality compared to those operated later. The objective of this study was to present regulatory measures aimed at promotion of early hip fracture surgery and their effect on the rates of early surgery and on postoperative mortality. DESIGN Retrospective cohort. SETTING Single inner‐city medical center. PARTICIPANTS Elderly patients with hip fractures operated during three time periods: 2006 to 2009 (n = 1735, no intervention), 2010 to 2013 (n = 2104, first intervention, positive reinforcement), and 2014 to 2016 (n = 1538, second intervention, positive and negative reinforcement). INTERVENTION Two regulatory measures were introduced consecutively: staff extra wages for afternoon operations (positive reinforcement) in 2010 and making early operation rates publicly available as the Ministry of Health Quality Care Indexes (negative reinforcement) in 2013. MEASUREMENTS Percentage of early surgeries and mortality at 1 month and 1 year postoperatively. RESULTS A total of 5377 patients (1595 men, 3782 women; mean age, 83.1 ± 7.2 years) underwent hip surgery between 2006 and 2016. The three study groups did not differ significantly in age on admission, sex, type of hip fracture (intracapsular or extracapsular), American Society of Anesthesiologists’ score, mean hemoglobin on admission, and mean socioeconomic status. The percentage of operations performed within 48 hours was 55%, 65%, and 85%, respectively (P < .001). One‐month mortality was 3.9%, 5.1%, and 5%, respectively (P > .05), and one‐year mortality was 19.2%, 18.7%, and 19.6%, respectively (P > .05). CONCLUSIONS Management pressure on the staff to expedite hip surgery and avoid negative publicity in conjunction with additional wages for afternoon surgeries was successful at promoting earlier hip surgery. Despite the substantial increase in the rates of early surgery, however, mortality rates were not affected. J Am Geriatr Soc 67:777–783, 2019.

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“…One‐year mortality was not assessed. Several other studies, however, did not report reduction of mortality with early surgery …”

Section: Discussionmentioning

confidence: 95%

Regulatory Measures Expedited Hip Fracture Surgery Without Lowering Overall Patient Mortality

Schermann

Gurel

Rotman

et al. 2018

J American Geriatrics Society

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“…Future fall prevention7. Anti-osteoporotic medication[22]Lizaur-Utrilla et al, 2016Spain2012–2014628Prospective cohort study1. Surgery within 2 days admission[23]Majumdar et al, 2006Canada1994–20003981Retrospective cohort study1.…”

Section: Resultsmentioning

confidence: 99%

“…No patients should be repeatedly fasted in preparation for surgery[36]––17. Time to surgery within a specific time frame[20, 22–28, 30–32, 34–38, 40–45]1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, 15, 16, 17, 19, 20, 21, 22, 25, 26, 27, 28, 29, 30P: 19, 30 [32, 43]NP: 7, 12, 21, 22, 25, 28, 29, 30 [22, 23, 34]NTI: 1, 2, 3, 4, 5, 6, 8, 11, 13, 15, 16, 17, 20, 25, 26, 27, 28, 30 [20, 24, 25, 30, 31, 35]18. Total operation time[45]––19.…”

Section: Resultsmentioning

confidence: 99%

“…Various time frames for surgical delay (varying from 24 to 48 h) are used in the definition of this QI. Sund et al [32] found a correlation between operative delay and a higher mortality rate; the other included articles found no correlation with the complication rate, place of residence after 3 months, functional status after 2 and 6 months, in-hospital mortality, and mortality after 3, 6, and 12 months [22, 23, 34]. The Hip fracture in Adults: Quality Standard 16 stated that delays in surgery are negatively associated with mortality and return to prefracture mobility [43].…”

Section: Discussionmentioning

confidence: 99%

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Quality indicators for hip fracture care, a systematic review

et al. 2018

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Quality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality indicators for hip fracture care reported in literature, hip fracture audits, and guidelines. The secondary aim was to compose a set of methodologically sound quality indicators for the evaluation of hip fracture care in clinical practice. A literature search according to the PRISMA guidelines and an internet search were performed to identify hip fracture quality indicators. The indicators were subdivided into process, structure, and outcome indicators. The methodological quality of the indicators was judged using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. For structure and process indicators, the construct validity was assessed. Sixteen publications, nine audits and five guidelines were included. In total, 97 unique quality indicators were found: 9 structure, 63 process, and 25 outcome indicators. Since detailed methodological information about the indicators was lacking, the AIRE instrument could not be applied. Seven indicators correlated with an outcome measure. A set of nine quality indicators was extracted from the literature, audits, and guidelines. Many quality indicators are described and used. Not all of them correlate with outcomes of care and have been assessed methodologically. As methodological evidence is lacking, we recommend the extracted set of nine indicators to be used as the starting point for further clinical research. Future research should focus on assessing the clinimetric properties of the existing quality indicators.

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“…Lewis and Waddell 12 concluded that considerable variation in practice and inconsistent evidence leave uncertainty about the optimal timing of hip fracture surgery. LizaurUtrilla and col leagues 13 argued that there is no single timing of hip fracture repair that can be considered optimal for all, because of hetero geneity among patients, their injuries and their care needs. In the ‡The level of care of the facility from which the patient was transferred was identified by "the institution from type" field in the hospital discharge abstracts.…”

Section: Discussionmentioning

confidence: 99%