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

Abstract

BackgroundTo assess the relationship between surgical delay and mortality in elderly patients with hip fracture. Systematic review and meta-analysis of retrospective and prospective studies published from 1948 to 2011. Medline (from 1948), Embase (from 1974) and CINAHL (from 1982), and the Cochrane Library. Odds ratios (OR) and 95% confidence intervals for each study were extracted and pooled with a random effects model. Heterogeneity, publication bias, Bayesian analysis, and meta-regression analyses were done. Criteria for inclusion were retro- and prospective elderly population studies, patients with operated hip fractures, indication of timing of surgery and survival status.Methodology/Principal FindingsThere were 35 independent studies, with 191,873 participants and 34,448 deaths. The majority considered a cut-off between 24 and 48 hours. Early hip surgery was associated with a lower risk of death (pooled odds ratio (OR) 0.74, 95% confidence interval (CI) 0.67 to 0.81; P<0.000) and pressure sores (0.48, 95% CI 0.38 to 0.60; P<0.000). Meta-analysis of the adjusted prospective studies gave similar results. The Bayesian probability predicted that about 20% of future studies might find that early surgery is not beneficial for decreasing mortality. None of the confounders (e.g. age, sex, data source, baseline risk, cut-off points, study location, quality and year) explained the differences between studies.Conclusions/SignificanceSurgical delay is associated with a significant increase in the risk of death and pressure sores. Conservative timing strategies should be avoided. Orthopaedic surgery services should ensure the majority of patients are operated within one or two days.

Dedicated Perioperative Hip Fracture Comanagement Programs are Cost-effective in High-volume Centers: An Economic Analysis

“…However, we accounted for this by conducting a broad sensitivity analysis using confidence intervals shown across several meta-analyses [48,57,59], which shows that these results are consistent over a reasonable range of values for mortality benefit in patients who are brought to the operating room earlier. However, this may not necessarily mean that interventions that shorten time to the operating room actually improve mortality.…”

“…A model was created evaluating the treatment of geriatric patients (an average age of 80 years was used for the base case [23,30,36,56]) with osteoporotic hip fractures using (1) admission to a traditional single service, (2) universal admission to a formally comanaged service with a specifically dedicated geriatric healthcare team (with resources in place to expedite time to the operating room), or (3) a risk-stratified model where patients who were high risk and sicker are assigned to a comanagement service, and patients who are healthier, with less-complex conditions were admitted to a lower-cost traditional service. Costs and clinical outcome probabilities were based on reported values [3,4,12,17,19,23,37,43,48]. We used a societal basis for cost calculations, assuming an incremental cost-effectiveness ratio (ICER) threshold of USD 100,000 per quality-adjusted lifeyear (QALY) as a cutoff for cost-effective treatment [8].…”

“…In terms of postoperative mortality, we assumed a baseline 1-year mortality rate of 20% [12,23,30,36,56,57], with a 30% increase in mortality for patients with operative treatment delayed more than 48 hours, based on several meta-analyses [48,57,59]. The 95% CI of mortality increase was based on the broadest ranges given in these meta-analyses, and ranged from a 5% to a 49% increase.…”

Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score–matched observational cohort study

“…In hip fracture surgery, delay is associated with morbidity and mortality, 6,7 but for other surgeries, the effect of delay on outcomes is unclear. [8][9][10][11][12][13] Because it is very expensive to expand or reorganize operating room resources to improve access, [14][15][16] understanding the relation between delay and outcomes for all types of emergency surgery is needed.…”

A szakellátásban megjelenő osteoporosisos nők 10 éves csonttöréskockázata a FRAX® alapján

“…Hazai felmérés alapján a 60-90 éves combnyaktörött, műtéti kezelésben részesült betegek 9%-a 30 napon belül, 30%-a egy éven belül meghal [4,5]. Nemzetközi viszonylatban is hasonlóan magas halálozási arányokat közöltek [6].…”