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Researchers examine delays in hip fracture repair surgery and patient outcomes

Over 350,000 people suffer a hip fracture each year, and costs associated with hospitalization alone are estimated at nearly $6 billion a year. Although hip fracture patients typically are women 80 years of age and older, about one-fourth of hospital discharges for hip fractures are men.

Two new studies supported in part by the Agency for Healthcare Research and Quality (HS09459) examined hip fracture repair among people aged 50 and older. The first study found that these patients commonly wait more than 24 hours from the time they are hospitalized to surgical hip repair. The second study identified eight patient subgroups with distinct clinical features that help predict likely 6-month outcomes following hip repair surgery. Both studies are described here.

Orosz, G.M., Hannan, E.L., Magaziner, J., and others. (2002). "Hip fracture in the older patient: Reasons for delay in hospitalization and timing of surgical repair." Journal of the American Geriatrics Society 50, pp. 1336-1340.

Some studies suggest that early surgical repair decreases mortality after hip fracture, while others indicate that delay in surgery is not detrimental. Timing of surgery may also affect the rate of postoperative complications, functional recovery and independence, and length of hospital stay. For this study, the researchers quantified the delay that occurred in initiating surgical repair in hip fracture patients aged 50 and older admitted to four New York City hospitals in 1997 and 1998. The investigators recorded time of the hip fracture, time of arrival to the emergency room, and time of surgery.

Over two-thirds of patients underwent hip repair surgery more than 24 hours after arriving at the hospital. Some of this delay time was patient-related and some occurred because of system factors that may be avoidable. Of the 571 study patients, 17 percent arrived at the hospital more than 24 hours after the hip fracture. After hospital arrival, 3 percent of patients did not have surgery, 29 percent had surgery within 24 hours, and 68 percent had surgery more than 24 hours after arrival. For those patients who underwent surgery after 24 hours, 29 percent had surgery 25 to 36 hours after hospital arrival, 18 percent had surgery 37 to 48 hours after arrival, and 22 percent had surgery more than 48 hours after arrival.

Over half (52 percent) of the patients had their surgery delayed more than 24 hours due to waits for routine medical clearance, and 29 percent were delayed due to the unavailability of the operating suite or surgeon. Stabilization of associated medical problems (for example, hematological, cardiopulmonary, or infectious conditions) resulted in the longest delays.

There currently are no standards for preoperative evaluation of hip fracture patients, and testing ordered for routine clearance varies widely. Differences between hospitals in the time of surgery suggests that improvements in practice are possible, but addressing these systems factors is complex, conclude the researchers.

Eastwood, E.A., Magaziner, J., Wang, J., and others. (2002). "Patients with hip fracture: Subgroups and their outcomes." Journal of the American Geriatrics Society 50, pp. 1240-1249.

Patient outcomes after hip fracture repair surgery vary depending on which of eight clinical subgroups a patient belongs to prior to surgery, conclude these authors. They used medical record data and patient/proxy interviews to prospectively study 571 older adults with hip fracture (most of whom were women, average age 82) in 1997 and 1998 at the time of hospitalization and 6 months later. They used cluster analysis to describe patients' baseline functioning prior to surgery and develop a patient classification tree with associated patient outcomes 6 months after hip fracture.

The researchers identified eight patient subgroups (clusters) that had distinct baseline features and variable outcomes at 6 months. For example, the first cluster—mostly middle-aged patients who were almost completely functionally independent—had the highest percentage of men and few coexisting medical problems. At 6 months postfracture, these patients were somewhat lower functioning than prefracture, but they continued to be the most independent of all the patients.

The fourth cluster of nearly independent very old (average age of 87 years) individuals was closest to a general profile of hip fracture patients. At baseline, this group had mild impairment in locomotion and near independence in the other functional areas. Nearly half (46 percent) had evidence of some dementia. At 6 months, the mortality rate was still low (8 percent), but they had not returned to prefracture functioning. The eighth cluster, the oldest old (aged 95 to 101), generally lived at home, had dementia, and had significant functional deficits at baseline. They regained impaired locomotion status at 6 months but went from independent to dependent bladder and bowel control.

For each functional subscale (locomotion, self-care, sphincter control, transfers, and total functional independence), functioning 6 months after hospitalization was highly dependent on baseline function. Knowing what outcomes to anticipate can help in planning the types of assistance a patient will need after hospitalization, as well as discharge location. In this study, 47 percent of patients were discharged to rehabilitation in nursing homes, 22 percent to acute medical rehabilitation facilities, 15 percent to home, and 14 percent to nursing home placement.

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