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Original Investigation
November 28, 2017

Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery

Author Affiliations
  • 1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
  • 2Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  • 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 4Sunnybrook Health Sciences Centre, Department of Surgery, Toronto, Ontario, Canada
  • 5Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
JAMA. 2017;318(20):1994-2003. doi:10.1001/jama.2017.17606
Key Points

Question  What is the association between wait time and 30-day mortality in patients undergoing hip fracture surgery?

Findings  In this retrospective cohort study that included 42 230 adults, wait time longer than 24 hours was associated with higher risk-adjusted likelihood of 30-day mortality (6.5% vs 5.8%).

Meaning  A wait time of 24 hours may represent a threshold of increased risk for delaying hip fracture surgery.

Abstract

Importance  Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications.

Objective  To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases.

Design, Setting, and Participants  Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs).

Exposure  Time elapsed from hospital arrival to surgery (in hours).

Main Outcomes and Measures  Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia).

Results  Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89).

Conclusions and Relevance  Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

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