Variation in surgical demand and time to hip fracture repair: a Canadian database study

Abstract Background Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals. Methods We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay. Results For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1–6.1), 12.2% (95% CI 10.3–14.2), and 22.0% (95% CI 17.7–26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay. Conclusion Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

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Evaluation of the volume-value relationship in hip fracture care using evidence-based thresholds

Hip International ◽

10.1177/1120700019837130 ◽

2019 ◽

Vol 30 (3) ◽

pp. 347-353

Author(s):

Sergio M Navarro ◽

William C Frankel ◽

Heather S Haeberle ◽

Damien G Billow ◽

Prem N Ramkumar

Keyword(s):

Hip Fracture ◽

Operating Characteristic ◽

Care Delivery ◽

High Volume ◽

Fracture Repair ◽

Fracture Care ◽

Hip Fracture Surgery ◽

Lower Volume ◽

Relative Market Share ◽

Fracture Surgery

Background: Studies have shown high-volume surgeons and hospitals deliver higher value care. The aims of this study were to establish meaningful thresholds defining high-volume surgeons and hospitals performing hip fracture surgery and to examine the relative market share of hip fracture cases using these surgeon and hospital strata. Methods: We performed a retrospective cohort study in a database of 103,935 patients undergoing hip fracture repair. We generated stratum-specific likelihood ratio (SSLR) models of a receiver operating characteristic (ROC) curve using length of stay (LOS) and cost value metrics. Volume thresholds predictive of decreased LOS and costs for surgeons and hospitals were identified. Results: Analysis of annual surgeon hip fracture volume produced two volume categories for LOS and cost: 0–30 (low) and 31+ (high). Analysis of LOS by annual hospital hip fracture volume produced strata at: 0–59 (low), 60–146 (medium), and 147 or more (high). Analysis of cost by annual hospital volume produced strata at: 0–125 (low) and 126+ (high). LOS and cost both decreased significantly ( p < 0.05) in progressively higher volume categories. Low-volume surgeons performed the majority of hip fracture cases, although they were performed at medium- or high-volume centres. Conclusions: This study demonstrates a direct relationship between volume and value, translating to improvement in hip fracture care delivery for both surgeons and hospitals. Higher volume hospitals while lower volume surgeons perform the majority of hip fracture cases, suggesting optimisation opportunities. However, systems-based practices at the hospital level likely drive value to a greater extent than individual surgeons.

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Vitamin D deficiency is associated with reduced mobility after hip fracture surgery: a prospective study

American Journal of Clinical Nutrition ◽

10.1093/ajcn/nqaa029 ◽

2020 ◽

Vol 112 (3) ◽

pp. 613-618 ◽

Cited By ~ 2

Author(s):

Lihong Hao ◽

Jeffrey L Carson ◽

Yvette Schlussel ◽

Helaine Noveck ◽

Sue A Shapses

Keyword(s):

Vitamin D ◽

Hip Fracture ◽

Nutritional Status ◽

Vitamin D Deficiency ◽

Risk Index ◽

Fracture Repair ◽

Nutritional Risk ◽

Hip Fracture Surgery ◽

Nutritional Risk Index ◽

Fracture Surgery

ABSTRACT Background Hip fractures are associated with a high rate of morbidity and mortality, and successful ambulation after surgery is an important outcome in this patient population. Objective This study aims to determine whether 25-hydroxyvitamin D [25(OH)D] concentration or the Geriatric Nutritional Risk Index (GNRI) is associated with mortality or rates of walking in a patient cohort after hip fracture surgery. Methods Patients undergoing hip fracture repair from a multisite study in North America were included. Mortality and mobility were assessed at 30 and 60 d after surgery. Serum albumin, 25(OH)D, and intact parathyroid hormone were measured. Patients were characterized according to 25(OH)D <12 ng/mL, 12 to <20 ng/mL, 20 to <30 ng/mL, or ≥30 ng/mL. GNRI was categorized into major/moderate nutritional risk (<92), some risk (92 to <98), or in good nutritional status (≥98). Results Of the 290 patients [aged 82 ± 7 y, BMI (kg/m2): 25 ± 5], 73% were women. Compared with patients with <12 ng/mL, those with higher 25(OH)D concentrations had higher rates of walking at 30 d (P = 0.031): 12 to <20 ng/mL (adjusted OR: 2.61; 95% CI: 1.13, 5.99); 20 to <30 ng/mL (3.48; 1.53, 7.95); ≥30 ng/mL (2.84; 1.12, 7.20). In addition, there was also greater mobility at 60 d (P = 0.028) in patients with higher 25(OH)D compared with the reference group (<12 ng/mL). Poor nutritional status (GNRI <92) showed an overall trend to reduce mobility (unadjusted P = 0.044 and adjusted P = 0.056) at 30 but not at 60 d. There was no association of vitamin D or GNRI with mortality at either time. Conclusions Vitamin D deficiency (<12 ng/mL) is associated with reduced ambulation after hip fracture surgery, whereas GNRI also contributes to immobility but is a less reliable predictor. Mechanisms that can explain why vitamin D deficiency is associated with mobility should be addressed in future studies.

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High volumes of recent surgical admissions, time to surgery, and 60-day mortality

The Bone & Joint Journal ◽

10.1302/0301-620x.103b2.bjj-2020-1581.r1 ◽

2021 ◽

Vol 103-B (2) ◽

pp. 264-270

Author(s):

Sara Marie Nilsen ◽

Andreas Asheim ◽

Fredrik Carlsen ◽

Kjartan Sarheim Anthun ◽

Lars Gunnar Johnsen ◽

...

Keyword(s):

Hip Fracture ◽

High Volume ◽

Surgical Patients ◽

Hospital Capacity ◽

Delayed Surgery ◽

Time To Surgery ◽

Hip Fracture Surgery ◽

Mortality Hazard Ratio ◽

Fracture Surgery ◽

Surgical Admission

Aims Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. Methods This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. Results Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). Conclusion A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264–270.

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Retrospective Analysis of Geriatric Patients Undergoing Hip Fracture Surgery: Delaying Surgery Is Associated With Increased Morbidity, Mortality, and Length of Stay

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459318795260 ◽

2018 ◽

Vol 9 ◽

pp. 215145931879526 ◽

Cited By ~ 3

Author(s):

Andrew Bennett ◽

Hsin Li ◽

Aakash Patel ◽

Kevin Kang ◽

Piyush Gupta ◽

...

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hospital Mortality ◽

Retrospective Analysis ◽

Postoperative Morbidity ◽

Morbidity And Mortality ◽

Time To Surgery ◽

Hip Fracture Surgery ◽

Asa Classification ◽

Fracture Surgery

Introduction: Hip fractures are common in elderly patients. However, this population frequently presents with significant medical comorbidities requiring extensive medical optimization. Methods: This study sought to elucidate optimal time to surgery and evaluate its effect on postoperative morbidity, mortality, and length of stay (LOS). We performed a retrospective analysis of data collected from 2008 to 2010 on 841 patients who underwent hip fracture surgery. Patients were classified based on time to surgery and were also classified and analyzed according to the American Society of Anesthesiologists (ASA) physical classification system. Results: Patients with a delay of greater than 48 hours had a significant increase in overall LOS, postoperative days, and overall postoperative complications. Patients classified as ASA 4 had an odds ratio for postoperative morbidity of 3.32 compared to the ASA 1 and 2 group ( P = .0002) and 2.26 compared to the ASA 3 group ( P = .0005). Delaying surgery >48 hours was also associated with increased in-hospital mortality compared to 24 to 48 hours ( P = .0197). Increasing ASA classification was also associated with significantly increased mortality. Patients classified as ASA 4 had 5.52 times the odds of ASA 1 and 2 ( P = .0281) of in-hospital mortality. Those classified ASA 4 had 2.97 times the odds of ASA 3 ( P = .0198) of an in-house mortality. Anesthetic technique (spinal vs general) and age were not confounding variables with respect to mortality or morbidity. Discussion: Surgical timing and ASA classification were evaluated with regard to LOS, number postoperative days, morbidity, and mortality. Conclusions: Delaying surgery >48 hours, especially in those with increased ASA classification, is associated with an increase in overall LOS, postoperative days, morbidity, and mortality. However, rushing patients to surgery may not be beneficial and 24 to 48 hours of preoperative optimization may be advantageous.

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