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CMAJ. 2018 Aug 7;190(31):E923-E932. doi: 10.1503/cmaj.171512.

Mortality effects of timing alternatives for hip fracture surgery.

Author information

1
School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont. boris.sobolev@ubc.ca.
2
School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont.

Abstract

BACKGROUND:

The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.

METHODS:

We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.

RESULTS:

Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).

INTERPRETATION:

Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.

Conflict of interest statement

Competing interests: Boris Sobolev, Pierre Guy and the Collaborative report receiving grants from the Canadian Institutes of Health Research related to this work. Pierre Guy reports receiving grants from the Natural Sciences and Engineering Research Council of Canada, the Canadian Foundation for Innovation and the British Columbia Specialists Services Committee for work regarding hip fracture care, outside the submitted work. He has also received fees from the BC Specialists Services Committee (for a provincial quality improvement project on redesign of hip fracture care) and from Stryker Orthopaedics (as a product development consultant), outside the submitted work. He is a board member and shareholder in Traumis Surgical Systems Inc. and a board member for the Canadian Orthopaedic Foundation. He also serves on the speakers’ bureaus of AOTrauma North America and Stryker Canada. Suzanne Morin reports research grants from Amgen Canada, outside the submitted work. Jason Kim and Lisa Kuramoto report receiving grants from the Canadian Institutes of Health Research, during the conduct of the study. No other competing interests were declared.

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