Grand Rounds

Is There an Optimal Time-to-Surgery Threshold for Hip Fracture Surgery?

BACKGROUND AND PURPOSE:

Delaying hip fracture surgery is associated with increased mortality risk
- Wait time to surgery is used as a quality metric
- Data on optimal time-to-surgery is limited
Pincus et al. (JAMA, 2017) sought to discover if there is an optimal time frame from emergency room to hip fracture repair

Population-based, retrospective cohort study
Patients: Adults undergoing hip fracture surgery between 2009-2014
Main exposure: Wait time to surgery from arrival in the emergency department until surgery (hours)
Primary outcome was mortality within 30 days
Secondary outcome was a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia)

42,230 patients were included
- Mean (SD) age, 80.1 years (10.7)
- 70.5% women
- Mean time to surgery was 38.8 (28.8) hours
Overall, mortality at 30 days was 7.0%
Risk of complications increased when wait times were greater than 24 hours, regardless of the specific complication
13,731 patients who received surgery within 24 hours (early) were propensity-score matched to patients who received surgery >24 hours (delayed) to adjust for confounders
- 30 day mortality was 5.8% in the early group vs 6.5% in the delayed group
  - Absolute risk difference 0.79% (95% CI, 0.23%-1.35%)
- Composite outcome (mortality + complications) was 10.1% in the early group vs 12.2% in the delayed group
  - Absolute risk difference 2.16% (95% CI, 1.43%-2.89%)
- Risk of complications increased when wait times were greater than 24 hours, regardless of the specific complication

Increased wait time for hip replacement surgery was associated with a greater risk of mortality and other complications
The authors suggest that a 24-hour window could serve as a wait time threshold for patients with hip fracture upon arrival to the emergency department

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