Does time from fracture to surgery affect mortality and intraoperative medical complications for hip fracture patients?

Listen to Mr Andrew Duckworth interview Dr Sunniva Leer-Salvesen and Dr Jan-Erik Gjertsen about their paper "Does time from fracture to surgery affect mortality and intraoperative medical complications for hip fracture patients?: an observational study of 73,557 patients reported to the Norwegian Hip Fracture Register", published in the September 2019 issue of The Bone and Joint Journal.

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[00:00:00] Welcome everyone to this month's BJJ Podcast. I am Andrew Duckworth and a warm welcome to our podcast for the month of September from your team here at The Bone & Joint Journal. I'd like to thank all our readers and listeners for the comments and support we've received so far for our podcast series, as well as to our authors and many guests interviewers who have taken part so far. We really do appreciate all of their efforts.

So far this year, we've covered a range of topics, including a fascinating dialogue between Ian Murray and Dr. Scott Rodeo on cell therapies and orthopedic surgery. A series of podcasts have accompanied our supplements from the American Hip & Knee Society closed meetings, and recently found an excellent discussion with Professor Matt Costa, Mr. David Metcalf on they're really important paper looking at pay for performance and hip fracture outcomes in the UK. We do hope these podcasts are improving the accessibility and visibility of the studies we publish here for both you as our readers, as well as for our many authors. 

As you know, we hope that during the next 15 to 20 minutes or so we'll cover a range of aspects of the chosen study, emphasizing the important points of how the work has been designed, [00:01:00] as well as the key findings from the study and how these potentially fits into each of your day-to-day practice. With this month's discussion I suspect being relevant to many of our listeners. We also hope to give you a behind the scenes insight into how the authors have developed their study and give them the opportunity to put forward the key findings of their work. 

So today I have the pleasure of being joined by both Dr. Sunniva Leer-Salvesen and Dr. Jan-Erik Gjertsen from Heartland Hospital in Bergen, Norway to discuss their study entitled Does time from fracture surgery affect mortality and interoperative medical complications for hip fracture patients, an observational study of 73,557 patient reported to the Norwegian Hip Fracture Register, which we published in the September edition of the BJJ. Welcome Jan-Erik and Sunniva and a big thank you for both of you just taking the time to join us today. 

So if we move straight onto the paper, as you very nicely put in your paper, patients with hip fractures are a frail group with a recognized peri-operative and short-term mortality rate. You say in your paper that in Norway, the 30 day mortality of hip fractures is currently at 8%, which is fairly [00:02:00] consistent with here back in the UK, but the influence of the actual time to treating the hip fracture on both the short and long-term mortality is not yet clear.

So Sunniva, if I can come to you first, can you give us a brief introduction to the paper and what we currently know about the influence of the actual time to treating hip fractures on both the short and long term mortality? 

Yes. Thank you for your introduction to our work Andrew. Our paper is a register based study where we have combined data from Norwegian Hip Fracture Register, and the Norwegian Patient Registry. And as you said, we aimed to investigate mortality and risk of interoperative medical complications, depending on time to surgery for hip fracture patients. 

Throughout the year, several studies have aimed to investigate the effect of surgical delay for our refracture patients. Some studies find a higher in-hospital mortality and a higher 30-day mortality when surgical delay exceeds either 24 hours or 48 hours from admission to surgery.

Other studies on the other hand find no association between time to surgery and the patient. To [00:03:00] conclude no conclusions regarding time to surgery has been reached yet. For mortality, surgical delay has been connected to longer lengths of stay and morbidity, and for example urinary tract  infections and bedsores.

That's really interesting. And I think it's interesting that actually reading your paper, how there is the limitation of the data in the area. It's one of these things we presume there is quite a bit out there, but there isn't. So yeah. And Jan-Erik, I will come to you next, can you give us a brief overview of the current guidelines in Norway in relation to regards time to surgery for hip fracture patients?

Yes. There has actually not been any official guidelines in Norway regarding time to surgery until recently, however, there is a note from the national knowledge center of health service from 2015,  recommending treatment within 24 hours, if possible, or at least within 48 hours. And the national quality [00:04:00] indicator for operation is operation within 48 hours but in 2018, a new multidisciplinary guidelines on treatment of hip fractures were introduced. And they recommend the treatment within 24 hours.  But these guidelines are not yet approved by the director of health so they are currently only recommendations from a working group, which consists of orthopedic surgeons, geriatricians, and anesthesiologists. But this document has been sent to all hospitals treating hip fractures. So there is an increased interest of multidisciplinary treatment of hip fractures, including focus on treatment within 24 hours. 

Yeah, that's really interesting. The fact that they are obviously just like you say recommendation rather than guidelines as we talked to Professor Matt Costa last month, and obviously we have certainly in England they have a sort of incentive-based system where, you know, getting these patients [00:05:00] too early is a criteria - that's really interesting.

So if we sort of move on to how the study was performed. So obviously, as you've already said, s this is big data utilizing data from the Norwegian hip fracture register and the Norwegian patient registry, which we all know are very good to sort of investigate whether the time from the moment of the fracture, rather than the time from hospital admission, per se influenced the mortality. 

So if Jan-Erik, I can just stay with you for a minute - obviously the study relied on these two national databases. Can you, from your position, could you give us a brief overview of these and what they sort of contain and collect routinely? 

Yes. First of all, the Norwegian hip fracture registry is a register that was established in 2005 to collect the nationwide information on treatment of hip fractures as a basis for improvement of treatment. And it now includes data from almost 120,000 patients. And the registry is owned by The Norwegian [00:06:00] Orthopedic Association. And it is co-located with the Norwegian arthroplasty register here in Bergen. And the register collects data  from each surgery by use of paper forms, which is filled in by surgeons immediately after each operation. And this paper form includes information on the patients such as ASA classification and cognitive function. And in addition information on the age and gender is given by the national identification number. And the form also includes information on time of fracture, the type of fracture and the type of surgery performed and several details about the surgery, including also interoperative complications. And we include both primary operations and reoperations, and we link them together with the help of the national identification number.

[00:07:00] And we also receive data from the Norwegian register of vital statistics with information on dates of death and dates of immigration. Okay. And then this study we also used the Norwegian patient registry. This is one of the central health registries in Norway. It is a register that receives administrative data on patients from all hospitals. So all admissions to Norweigian hospitals are recorded in this registry and the registry also has information on exact time of admission that we used in our study and by use of the identification number, it was possible to link data from the Norwegian patient registry and Norwegian hip fracture register.

Right. That's that's brilliant. That's a really nice, clear overview of what the data collects. And obviously a very concise but also robust system. That's brilliant. So Sunniva, if I come back to you, what were the really primary and [00:08:00] secondary outcomes or goals you were sort of looking at for the study itself?

Yeah, the primary outcome in our study was mortality following hip fracture surgery, and we chose the secondary outcome to be the risk of reported intraoperative complications for our patients. An important factor is that all existing research to our knowledge targets the hospital delay, meaning the time from admission to surgery. We chose to study both the prehospital hours and hospitable hours then targeted the total delay for any fracture patients. We chose to study our outcomes, both investigating hospital delay and total delay. 

Okay. Okay. And that makes a lot of sense. And in terms of, you sort of perform two analyses, predominantly sort of two primary analyses, and you have sort of different numbers of hip fracture patients in those two analyses, can you just sort of explain for our listeners why that is?

Yes, we have used two different patients groups when investigating total delay and hospital delay. As my coworker mentioned, we [00:09:00] have used data from the Norwegian Hip Fracture register and the Norwegian patient registry. And the time of fracture is gathered from the Norwegian hip fracture registers by forms filled out by the independent surgeons. And in about 47% of the cases, we do not know the exact time of fracture or the exact time of fracture for our patients isn't reported. That's where we ended up with about 39,000 patients when investigating total delay. 

When we investigated the hospital length, we gathered information of time of admission from the Norwegian patient registry. And this is a administratively reported and constitutes the ground for activity-based financing for the hospitals and therefore these data are nearly complete. Therefore we were able to study about 73,000 patients when I am investigating hospital delay.

Fine. That's very clear. That makes a lot of of sense, why there's the two different numbers of patients. And obviously you have a variety of very robust and nicely performed [00:10:00] analyses in the manuscript. But just for our listeners, can you just sort of give them a simple, concise overview of the analyses you performed? 

Hmm. Yes, of course. For our primary  outcome, the morality we used Cox multiple regression models to compare the relative risks of postoperative death among patients divided into groups based on the preoperative delay. We adjusted our analyses for possible influences of age, sex, co-morbidity using the ASA score and the types of surgery, and also the type of fractures. Yeah. Further on we divided our patients into groups based on a 12 hour intervals, either from the time of fracture or the time of admission to surgery. 

Okay. Okay, great. Great. That's very clear. And then obviously these can be quite a complicated analysis. That's a really nice way sort of clearly lay it out for our listeners. That's brilliant. So if we sort of move on to your results so if you look at sort of the known total delay group. [00:11:00] So nicely laid out in your first table. You had, like say you, over 38,000 patients there and the sort of the demographics are really, as we'd expect, you know, 70% are female, you know, over 60% have an ASA grade three or higher. And the most sort of common fracture type you're dealing with is a displaced intracapsular neck of femur fracture, and most of those going on to hemiarthroplasty, but just for our listeners, can you give us sort of detailed key findings in relation to the total delay and mortality?

Yeah. First of all, we found no effect of total delay to affect the surgery as long as operations were performed within 48 hours from the fracture.

 Okay. 

However, total delay more than 48 hours were associated with increased mortality after three days postoperatively and one year post-operatively for any fracturepatients.

Okay. 

And further on, we went on to study co-morbidity and stratify the patients into the healthcare ASA one to two group, and then more comorbid patients with an ASA class, three to five. 

Yeah. 

[00:12:00] For these patients, we found that total delay of more than 48 hours was associated with an increased three-day mortality for the comorbid patients while the healthier patients groups did not have an altered mortality.

Yeah. And then we went on to study patients based on their type of surgery performed. We studied patients with osteosynthesis and found that also these patients had an increased mortality if the total delay exceeded 48 hours from fracture to surgery. However, when studying patients receiving osteosynthesis, time to surgery did not seem to influence the patient mortality at any point of observation.

Okay, brilliant. That's a really nice summary, cause obviously you've got a lot of robust analysis in there and then that's a really nice summary of what you sort of found. In terms of what did you find in terms of, you know, the hospital delay and sort of, I suppose rather more than mortality, the sort of medical complications that can potentially develop.

Oh yeah. We went on to study the hospital delay [00:13:00] and to start with you could say that in average, our patients waited 22 hours from admission to surgery in our study. Both we found out patients that waited more than 24 hours for surgery had an increased risk of reported intra-operative medical complications in our study. So to conclude, the limit for unwanted outcomes was even lower when studying these complications compared to mortality. 

Okay. Okay. That's really interesting. I mean, I think they're really, really interesting findings and obviously very robust in such a large group of patients. If we sort of move away from the results now and onto the sort of the implications study, I suppose, and sort of given its findings and it's clearly provided strong  evidence with regards to time to surgery and mortality and the strengths of the surgery, of the study, sorry, are clearly without doubt in that, you know, big data, large number of patients from what appear to be very comprehensive national databases, as well as the robust [00:14:00] analyses performed.

But if I come back to you. What do you feel are the key findings of the work? You know, considering, I suppose, any potential limitations you feel there are to the data itself. 

I think the key finding is that hip fracture should be operated within 48 hours after the fracture. And not within 48 hours after admission. And further the number of reported medical complications were higher when hospital length exceeded 24 hours. But there are some limitations, even if we adjusted for age sex and ASA class, there may be confounders that we did not adjust it for.  For example, it is difficult to conclude whether the medical complications occurred due to the long waiting time to surgery, or whether the patients waited longer to surgery because they have co-morbidities that had to be stabilized before surgery and that they therefore had an increased risk of [00:15:00] incorporative medical complications that we were not able to adjust for.

Yeah. 

And that's interesting. And so when you look at sort of the results from previous studies, sort of, particularly the, sort of the details of the fast track, hip fracture, you sort of mentioned how do you feel that these are related to your study? 

Yeah, I think our results actually compare well both with the new Norwegian multiple disciplinary guidelines recommending surgery within 24 hours. And also with the, for example, the NICE Guidelines in UK, recommending treatment within 36 hours, that means that the patients have to be operated the day of admission or the next day. And only have one night at hospital without surgery.

And our results also compare well to a large meta-analysis from Shiga and colleagues that found increased one-year mortality and 30-day mortality for patients waiting longer than 48 [00:16:00] hours.

Yeah, no, I totally agree. I think it does fit well with the current other literature in there available and the other recommendations from other countries. So if I just come back to you. As I sort of alluded to, you sort of pose an interesting question in the paper. And so do you feel it is that the surgery was delayed because of patients increased risk of unwanted outcomes or if the unwanted  outcomes sort of occurred due to the delayed surgery, it's sort of a difficult one, isn't it? What's your sort of feeling on that? 

Yes. It's a hard question to answer, because we know that both in earlier studies and our own study, a high level of comorbidity has been reported among patients with a long hospital delay compared to the patients with earlier surgical interventions. Therefore we are, as you mentioned, potentially facing a question of confounding by indication in our study. And we think that to fully investigate the dilemma, we need other studies to understand our observational register study, and an example, randomized controlled trials, where can [00:17:00] target the consequences of co-morbidity and pre-operative management in a more deeper way. 

However, in our study, we tried to give close understanding by separately studying our outcomes among the healthier patient groups, the ASA one to two class patients and excluding the comorbid patients and these healthier patients are less likely to be delayed because of co-morbidity and more likely to be delayed due to administrative factors, in example, lack of surgical staff or equipment or facilities. 

We found that the risk of mortality and complications increased when delay exceeded 48 hours also in the healthier patient group. And based on these findings, I do believe that delayed surgery contributes to unwanted outcomes. 

But of course, we need to acknowledge that certain medical complications are crucial to optimize preoperatively to reduce complications both under and after surgery. And in these cases, time to surgery may need to be a less prioritised. 

 Yeah, no, I think that's a [00:18:00] very nice way to put it because like you say, it's a very difficult sort of question to answer and I think that's, it's a nice way to look at it. 

So yeah, I'll just come to you sort of finally, what do you feel are the potential implications of this study moving forward, I suppose, for you back in Norway, but also for worldwide. What do you think the potential communications will be?

I think it's important to keep in mind, to focus on the time from facture to surgery, particularly Norway with a long way to hospital for  many patient. And most other studies and guidelines, they focus on the time from admission to surgery. But the waiting time to surgery is a very vulnerable time for the patients, but the most vulnerable period is probably the time between fracture and admission because in that period patients have a lot of pain. They are immobilized, perhaps on the floor, perhaps for several hours, if they live alone before they get help. [00:19:00] And the waiting time starts when the patients fall and not when the patients are admitted to hospital. So a patient who has a long prehospital waiting period must be prioritized for surgery after admission. 

And our results also show that we don't have to rush too much to surgery. The results do not support that hip fractures must be treated faster than within 24 hours. So there is probably no need to operate hip fractures at night. It's probably better both for the patients and the surgeons to perform surgery at daytime. 

Yeah, no, I totally agree. I think it's a really nice, really nice way to, to sum up your study. And I'm afraid that's all we probably have time for now, but thank you are thank you so much for joining us for our podcast and congratulations on a really excellent study that I'm sure has given all of our listeners much food for thought. And to our listeners, we do hope you've enjoyed joining us and we encourage you to share your thoughts and comments through Twitter, Facebook, and a like. And feel free to post a tweet about anything we've discussed here today. And [00:20:00] thanks again for joining us.