title: Early surgery within 2 days for hip fracture is not reliable as healthcare quality indicator.
abstract: OBJECTIVE
  To analyze prospectively the influence of the timing of surgery on morbidity and mortality, and to assess whether the early surgery within 2 days admission may be a reliably healthcare quality indicator.
  
  
  METHODS
  Prospective observational study of 628 patients age 60 or older who had been co-managed between surgeons and internists. Based on the literature, many potential factors influencing outcomes were collected to control confounding regard to surgery delay, complications and mortality. Multivariate logistic regression and Cox regression models were used to assess effects on the delay and mortality, respectively.
  
  
  RESULTS
  Mean Charlson index was 2.3, and 284 patients had at least 3 comorbidities. Mean timing of surgery was 3.6 days (range 0-20). 418 patients were fit for surgery, of which 180 underwent surgery within 2 days. Delay for surgery more than 2 days was significantly associated with ASA >2, Charlson >2 and anticoagulant therapy. Medical complications were not significantly associated with delayed surgery more than 2 days. Mortality rate was 0.9% in-hospital, 3.4 at 1 month, 7.0% at 3 months, and 13.6% at 12 months. There were no significant differences in in-hospital, 3-month or 1-year mortality between patients operated within 2 days and those operated at 3-4 days, but delayed more than 4 days was associated with higher 1-year mortality. Likewise, patients readmitted within 30 days had higher in-hospital mortality. Excluding unfit for surgery patients at admission, there was no significant difference in 3-month or 1-year mortality between patients operated within 2 days and those with delayed surgery.
  
  
  CONCLUSIONS
  Delaying surgery up to 4 days was not associated with higher morbidity or mortality rates. We recommend concentrating more on preoperative optimizing the condition of patient with sufficient medical treatment rather than being bound by a universal timing of surgery.
authors.affiliation: Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain; Traumatology and Orthopaedia, Miguel Hernandez University, Elche, Alicante, Spain. Electronic address: lizaur1@telefonica.net.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Lizaur-Utrilla
authors.affiliation: Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain.
authors.forename: Daniel
authors.initials: D
authors.lastname: Martinez-Mendez
authors.affiliation: Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain.
authors.forename: Isabel
authors.initials: I
authors.lastname: Collados-Maestre
authors.affiliation: Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain.
authors.forename: Francisco A
authors.initials: FA
authors.lastname: Miralles-Muñoz
authors.affiliation: Orthopaedic Surgery, Elda University Hospital, Elda, Alicante, Spain.
authors.forename: Luis
authors.initials: L
authors.lastname: Marco-Gomez
authors.affiliation: Traumatology and Orthopaedia, Miguel Hernandez University, Elche, Alicante, Spain.
authors.forename: Fernando A
authors.initials: FA
authors.lastname: Lopez-Prats
mesh_terms: D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000401:mortality; D015897:Comorbidity; D005260:Female; D006620:Hip Fractures / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D016015:Logistic Models; D008297:Male; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D012720:Severity of Illness Index; D013030:Spain / Q000453:epidemiology; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D016896:Treatment Outcome
keywords: Complications; Hip fracture; Mortality; Predictors; Timing of surgery