Are the current guidelines for surgical delay in hip fractures too rigid? A single center assessment of mortality and economics

• Published in: Injury 2018-06, Vol.49 (6), p.1169-1175
• Main Authors: Kempenaers, Kristof, Van Calster, Ben, Vandoren, Cindy, Sermon, An, Metsemakers, Willem-Jan, Vanderschot, Paul, Misselyn, Dominique, Nijs, Stefaan, Hoekstra, Harm
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip - economics; Arthroplasty, Replacement, Hip - methods; Arthroplasty, Replacement, Hip - statistics & numerical data; Cause of Death; Economics; Female; Fracture Fixation, Intramedullary - economics; Fracture Fixation, Intramedullary - methods; Fracture Fixation, Intramedullary - statistics & numerical data; Health Care Costs - statistics & numerical data; Hip Fractures - economics; Hip Fractures - mortality; Hip Fractures - surgery; Humans; Logistic Models; Male; Mortality; Odds Ratio; Practice Guidelines as Topic; Proximal femoral fractures; Quality Indicators, Health Care; Retrospective Studies; Risk Assessment; Surgical delay; Survival Rate - trends; Time-to-Treatment - economics; Time-to-Treatment - statistics & numerical data
• ISSN: 0020-1383; 1879-0267
• DOI: 10.1016/j.injury.2018.03.032

Controversy remains around acceptable surgical delay of acute hip fractures with current guidelines ranging from 24 to 48 h. Increasing healthcare costs force us to consider the economic burden as well. We aimed to evaluate the adjusted effect of surgical delay for hip fracture surgery on early mortality, healthcare costs and readmission rate. We hypothesized that shorter delays resulted in lower early mortality and costs. In this retrospective cohort study 2573 consecutive patients aged ≥50 years were included, who underwent surgery for acute hip fractures between 2009 and 2017. Main endpoints were thirty- and ninety-day mortality, total cost, and readmission rate. Multivariable regression included sex, age and ASA score as covariates. Thirty-day mortality was 5% (n = 133), ninety-day mortality 12% (n = 304). Average total cost was €11960, dominated by hospitalization (59%) and honoraria (23%). Per 24 h delay, the adjusted odds ratio was 1.07 (95% CI 0.98–1.18) for thirty-day mortality, 1.12 (95% CI 1.04–1.19) for ninety-day mortality, and 0.99 (95% CI = 0.88–1.12) for readmission. Per 24 h delay, costs increased with 7% (95% CI 6–8%). For mortality, delay was a weaker predictor than sex, age, and ASA score. For costs, delay was the strongest predictor. We did not find clear cut-points for surgical delay after which mortality or costs increased abruptly. Despite only modest associations with mortality, we observed a steady increase in healthcare costs when delaying surgery. Hence, a more pragmatic approach with surgery as soon as medically and organizationally possible seems justifiable over rigorous implementation of the current guidelines.