• Daniel Pincus, Bheeshma Ravi, David Wasserstein, Anjie Huang, J Michael Paterson, Avery B Nathens, Hans J Kreder, Richard J Jenkinson, and Walter P Wodchis.
• Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
• JAMA. 2017 Nov 28; 318 (20): 1994-2003.

ImportanceAlthough 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.ObjectiveTo 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 ParticipantsPopulation-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).ExposureTime elapsed from hospital arrival to surgery (in hours).Main Outcomes And MeasuresMortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia).ResultsAmong 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 RelevanceAmong 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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