Is the Delay to Surgery for Isolated Hip Fracture Predictive of Outcome in Efficient Systems?

Bergeron, Éric; Lavoie, André; Moore, Lynne; Bamvita, Jean‐Marie; Ratte, Sebastien; Gravel, Charles; Clas, David

doi:10.1097/01.ta.0000214649.53190.2a

Cited by 82 publications

(74 citation statements)

References 30 publications

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“…La demora debe ser la mínima siempre que permita llevar a cabo la intervención en condiciones adecuadas, aunque la literatura muestra resultados controvertidos al medir su asociación con la mortalidad. Mientras dos estudios canadienses y dos norteamericanos no aprecian una relación estadística-mente significativa [11][12][13][14] , otros trabajos seña-lan que la mayor demora en la cirugía produce un aumento de la mortalidad [15][16][17] . Aunque la mayor parte de los trabajos de la literatura consisten, como el nuestro, en estudios transversales basados en el CMBD, es difícil comparar los resultados, ya que las metodologías no son siempre las mismas sin que se pueda encontrar un patrón definido.…”

Section: Discussionunclassified

Mortalidad y costes asociados a la demora del tratamiento quirúrgico por fractura de cadera

Etxebarría-Foronda

Mar

Arrospide

et al. 2013

Rev. Esp. Salud Publica

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RESUMENFundamentos: La intervención quirúrgica en las fracturas de cadera suele demorarse varios días. Nuestro trabajo tiene dos objetivos. Estudiar la estancia preoperatoria de los pacientes ingresados por fractura de cadera en los hospitales vascos durante el año 2010 y medir su posible asociación con la mortalidad intrahospitalaria, y estimar el coste económico que supone la estancia preoperatoria.Métodos. Se realizó un estudio observacional analizando los siguientes datos del Conjunto Mínimo Básico de Datos (CMBD): hospital, edad, sexo, estancia preoperatoria, estado al alta, diagnósticos asociados y procedimiento quirúrgico. Además, se estudió el índice de comorbilidad de Charlson y se calculó el coste unitario de la estancia pre y postoperatoria mediante modelos de regresión múltiple.Resultados. Se analizó una muestra de 1.856 intervenciones. La estancia preoperatoria fue de 2,7 días y la postoperatoria de 9,7 días. El coste medio por ingreso fue de 12.552,12 euros. El coste medio de la estancia preoperatoria fue de 1295,5 euros. La mortalidad fue del 5%.Conclusiones. La estancia preoperatoria no es un factor estadística-mente asociado con la mortalidad, aunque aumenta significativamente el coste total. No encontramos una asociación entre la demora quirúrgica y la mortalidad, aunque sí tiene una clara influencia en el coste total del proceso. La reducción del tiempo prequirúrgico permite ahorrar costes. Background: Hip fractures surgery is often delayed for several days. The present work has two objectives. The first one is to determine the preoperative hospital length of stay of patients with a hip fracture in our region and its possible correlation with an increase in mortality rate. Secondly we assessed the healthcare expenditure associated to this preoperative period.

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Section: Discussionunclassified

Mortalidad y costes asociados a la demora del tratamiento quirúrgico por fractura de cadera

Etxebarría-Foronda

Mar

Arrospide

et al. 2013

Rev. Esp. Salud Publica

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“…Twenty-one of these were excluded, 13 with insufficient data and eight that did not meet our criteria. Thus, five prospective 13-17 and 11 retrospective studies 5,6,[18][19][20][21][22][23][24][25][26] were included in our analysis. One report 17 was excluded from the analysis of 30-day mortality because of possible duplication with another study; 13 but it was included in the analysis of one-year mortality because the other study 13 was not included in this analysis.…”

Section: Resultsmentioning

confidence: 99%

“…The median quality index was 14 (range: 11-17). Thirteen trials 5,6,13,15,16,[19][20][21][22][23][24][25][26] (236,179 patients) evaluated 30-day mortality in association with early vs delayed surgery. Mortality occurred in 5,438 of 54,988 patients for whom surgery was delayed and in 12,580 of 181,191 patients for whom surgery was early.…”

Section: Resultsmentioning

confidence: 99%

“…Six retrospective studies 5,6,19,[22][23][24] computed an adjusted odds ratio for 30-day mortality; and two retrospective studies 20,23 computed an adjusted odds ratio for one-year mortality by means of a multivariate logistic regression model or multivariate Cox proportional hazards model. Therefore, we combined the adjusted odds ratios for 30-day and one-year mortality; and we compared these values with the unadjusted (crude) odds ratios.…”

Section: Subgroup and Sensitivity Analysismentioning

confidence: 99%

“…The odds ratio for 30-day mortality in one study in which the cut-off was 24 hr 19 was 1.56 (95% CI, 1.27-1.91), and that for one-year mortality in one study 18 was 1.45 (95% CI, 0.57-3.72). The odds ratio for 30-day mortality in 11 studies that used a cut-off time of 48 hr 5,6,13,16,[20][21][22][23][24][25][26] was 1.41 (95% CI, 1.29-1.54, Cochran Q statistic = 26.2, P for heterogeneity = 0.003), and that for one-year mortality in seven studies 6,17,20,22,23,25,26 was 1.32 (95% CI, 1.21-1.43, Cochran Q statistic = 16.0, P for heterogeneity = 0.013). The odds ratio for 30-day mortality in one study 15 that used a cut-off of 72 hr was 1.56 (95% CI, FIGURE 3 Forest plot of odds ratios for the impact of operative delay on one-year mortality.…”

Section: Subgroup and Sensitivity Analysismentioning

confidence: 99%

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Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression

Shiga

Wajima

Ohe

2008

Can J Anesth/J Can Anesth

561

338

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Purpose: Mortality associated with hip fracture is high in elderly patients. Surgical repair within 24 hr after admission is recommended by The Royal College of Physicians' guidelines; however, the effect of operative delay on mortality remains controversial. The objective of this study was to determine whether operative delay increases mortality in elderly patients with hip fracture. Methods: Published English-language reports examining the effect of surgical delay on mortality in patients who underwent hip surgery were identified from electronic databases. The primary outcome was defined as all-cause mortality at 30 days and at one year. Effect sizes with corresponding 95% confidence intervals were calculated by using a DerSimonian-Laird randomeffects model. Results:Sixteen prospective or retrospective observational studies (257,367 patients) on surgical timing and mortality in hip fracture patients were selected. When a cut-off of 48 hr from the time of admission was used to define operative delay, the odds ratio for 30-day mortality was 1.41 (95% CI = 1.29-1.54, P < 0.001), and that for one-year mortality was 1.32 (95% CI = 1.21-1.43, P < 0.001). Conclusions: In hip fracture patients, operative delay beyond 48 hr after admission may increase the odds of 30-day all-cause mortality by 41% and of one-year all-cause mortality by 32%. Potential residual confounding factors in observational studies may limit definitive conclusions. Although routine surgery within 48 hr after admission is hard to achieve in most facilities, anesthesiologists must be aware that an undue delay may be harmful to hip fracture patients, especially those at relatively low risk or those who are young.

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Association of Patient-Level and Hospital-Level Factors With Timely Fracture Care by Race

et al. 2022

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ImportanceRacial disparities in treatment benchmarks have been documented among older patients with hip fractures. However, these studies were limited to patient-level evaluations.ObjectiveTo assess whether disparities in meeting fracture care time-to-surgery benchmarks exist at the patient level or at the hospital or institutional level using high-quality multicenter prospectively collected data; the study hypothesis was that disparities at the hospital-level reflecting structural health systems issues would be detected.Design, Setting, and ParticipantsThis cohort study was a secondary analysis of prospectively collected data in the PREP-IT (Program of Randomized trials to Evaluate Preoperative antiseptic skin solutions in orthopaedic Trauma) program from 23 sites throughout North America. The PREP-IT trials enrolled patients from 2018 to 2021, and patients were followed for 1-year. All patients with hip and femur fractures enrolled in the PREP-IT program were included in analysis. Data were analyzed April to September 2022.ExposuresPatient-level and hospital-level race, ethnicity, and insurance status.Main Outcomes and MeasuresPrimary outcome measure was time to surgery based on 24-hour time-to-surgery benchmarks. Multilevel multivariate regression models were used to evaluate the association of race, ethnicity, and insurance status with time to surgery. The reported odds ratios (ORs) were per 10% change in insurance coverage or racial composition at the hospital level.ResultsA total of 2565 patients with a mean (SD) age of 64.5 (20.4) years (1129 [44.0%] men; mean [SD] body mass index, 27.3 [14.9]; 83 [3.2%] Asian, 343 [13.4%] Black, 2112 [82.3%] White, 28 [1.1%] other) were included in analysis. Of these patients, 834 (32.5%) were employed and 2367 (92.2%) had insurance; 1015 (39.6%) had sustained a femur fracture, with a mean (SD) injury severity score of 10.4 (5.8). Five hundred ninety-six patients (23.2%) did not meet the 24-hour time-to-operating-room benchmark. After controlling for patient-level characteristics, there was an independent association between missing the 24-hour benchmark and hospital population insurance coverage (OR, 0.94; 95% CI, 0.89-0.98; P = .005) and the interaction term between hospital population insurance coverage and racial composition (OR, 1.03; 95% CI, 1.01-1.05; P = .03). There was no association between patient race and delay beyond 24-hour benchmarks (OR, 0.96; 95% CI, 0.72-1.29; P = .79).Conclusions and RelevanceIn this cohort study, patients who sought care from an institution with a greater proportion of patients with racial or ethnic minority status or who were uninsured were more likely to experience delays greater than the 24-hour benchmarks regardless of the individual patient race; institutions that treat a less diverse patient population appeared to be more resilient to the mix of insurance status in their patient population and were more likely to meet time-to-surgery benchmarks, regardless of patient insurance status or population-based insurance mix. While it is unsurprising that increased delays were associated with underfunded institutions, the association between institutional-level racial disparity and surgical delays implies structural health systems bias.

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Is the Delay to Surgery for Isolated Hip Fracture Predictive of Outcome in Efficient Systems?

Cited by 82 publications

References 30 publications

Mortalidad y costes asociados a la demora del tratamiento quirúrgico por fractura de cadera

Mortalidad y costes asociados a la demora del tratamiento quirúrgico por fractura de cadera

Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression

Association of Patient-Level and Hospital-Level Factors With Timely Fracture Care by Race

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