Early surgical treatment using regional clinical pathways reduces the length of postoperative hospitalization in hip fracture patients: A retrospective analysis using the Japanese Diagnosis Procedure Combination database

doi:10.21203/rs.3.rs-2453758/v1

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Early surgical treatment using regional clinical pathways reduces the length of postoperative hospitalization in hip fracture patients: A retrospective analysis using the Japanese Diagnosis Procedure Combination database

https://doi.org/10.21203/rs.3.rs-2453758/v1

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Background: Hip fracture is a common injury in older people, especially those with weak bone contracture such as in osteoporosis. Although early surgical treatment is recommended, the optimal timing has not yet been determined in Japan. Therefore, we ascertained the rate of early surgery among hip fracture patients and investigated its effectiveness, along with regional clinical pathways, in reducing the length of postoperative hospital stay among patients with hip fractures. We used the Japanese Diagnosis Procedure Combination (DPC) database to obtain data for this study.

Methods: We used data of patients diagnosed with femoral neck and peritrochanteric fractures retrieved from the Japanese DPC database between April 2016 and March 2018. Patients were divided into the early surgery (43,928 [34%] patients who underwent surgery within two days of admission) and delayed surgery groups (84,237 [66%] patients who underwent surgery after two days of admission).

Results: The difference between the length of stay (LOS) in the hospital for both groups was two days (early vs. delayed: 21 days vs. 23 days). The early surgery group had more cases of intertrochanteric fractures (57% vs. 43%) and internal fixation (74% vs. 55%) than the delayed surgery group. In contrast, the delayed surgery group had more cases of femoral neck fractures (43% vs. 57%) and bipolar hip arthroplasty (25% vs. 42%) or total hip arthroplasty (1.2% vs. 3.0%). Moreover, the early surgery group showed a lower incidence of complications, except anaemia (12 % vs. 8.8%), than the delayed surgery group. Logistic regression analysis using the adjusted model showed that early surgery and implementation of regional clinical pathways reduced LOS by 2.58 and 8.06 days, respectively (p < 0.001).

Conclusions: Early surgery was performed in a third of all hip fracture patients. Early surgery and implementation of regional clinical pathways for hip fracture patients are effective in reducing postoperative hospital LOS, with regional clinical pathways having a greater impact. These findings will help acute care providers when treating patients with hip fractures.

Hip fracture

early surgery

regional clinical pathway

postoperative hospital stay

postoperative complication

Diagnosis Procedure Combination database

Hip fracture is common among older people, especially in those with osteoporosis. It has been reported that approximately 200,000 hip fracture cases occurred in 2017 [1]. The number has been increasing worldwide, and it is estimated to increase globally to about seven million by 2050 [2]. Hip fracture affects not only the patient’s ability to perform activities of daily living (ADL), but also life prognosis. Regarding mortality, the percentage of older adults with a fractured hip who die within a year of injury is as high as 30%, while approximately 7% die during hospitalization [3–5]. Therefore, it is crucial to develop a concrete strategy for treating patients with hip fractures, especially older people.

The Japanese Orthopaedic Association has issued clinical guidelines for the treatment of hip fractures. However, there is a lack of clear statements regarding the best surgical approach, particularly the timing of surgery. The guideline suggests that surgeons should perform surgery “as soon as possible.” On the contrary, the clinical guidelines of the American Association of Orthopaedic Surgeons and the National Health Service (UK) recommend performing surgery “within 48 hours of hospital admission”. This indication is supported by the findings of previous studies that surgery for hip fracture delayed longer than 48 hours may increase the risk of severe complications. These include surgical site infection, pressure sores, and other major medical complications, or even in-hospital and one-year mortality [6–9]. However, some previous studies have reported no increase in complications or risk of one-year mortality among patients who underwent surgical treatment delayed by more than 48 hours after hospital admission [10–12].

In Japan, more attention has been paid to the implementation of regional clinical pathways to treat patients effectively and in a unified fashion. Regional clinical pathways are managed by outpatient clinics, acute care hospitals, rehabilitation hospitals, and care providers within a specific region to provide effective and consistent care. The protocol includes specifying the disease name, patient’s symptoms at the time of hospitalization, hospital name, scheduled medical examinations and medical procedures, period until standard transfer, details of care post transfer, discharge criteria, standard time course for total care period, and other essential information [13, 14]. The regional clinical pathways provide a series of support services which include fracture treatment and discharge to home. This benefits both patients and hospitals by reducing turnaround time and enabling the efficient utilization of hospital beds.

In the current study, we utilized data retrieved from the Diagnosis Procedure Combination (DPC) database, which is a Japanese nationally representative clinical database containing discharge abstract and administrative claim data. These include data regarding surgical procedures and medications indexed in the original Japanese codes assigned by the Ministry of Health, Labour, and Welfare of Japan [15].

The objectives of this study were to i) determine the rate of early surgery among hip fracture patients, ii) investigate the effect of early surgery and regional clinical pathways on the length of postoperative hospital stay, and iii) use the DPC database to compare the postoperative complications and changes in ADL of patients with hip fractures who underwent early and delayed surgery.

Data sources

Data retrieved from the Japanese DPC database between April 2016 and March 2018 were used. The study followed the principles of the Declaration of Helsinki and its later amendments. The protocol was approved by the Ethics Committee of Medical Care and Research of the University of Occupational and Environmental Health, Japan (approval no. R1-067). Due to the anonymised nature of the data, the requirement for informed consent was waived.

Data collection

Patient data labelled with the codes S72.0 (femoral neck fracture) and S72.1 (femoral peritrochanteric fracture), according to the International Classification of Diseases 10th revision, were extracted from the DPC database.

We also retrieved the data of patients who underwent open reduction and internal fixation (ORIF), bipolar hip arthroplasty (BHA), and total hip arthroplasty (THA) after admission. The following patients were excluded: (1) those with missing data (n = 10,825) and (2) those with a length of stay (LOS) > 120 days (n = 1,271). Ultimately, we enrolled 128,165 patients in this study. Patients who underwent surgery within two days after admission were assigned as the early surgery group, and those who underwent surgery over two days after admission were the delayed surgery group (Fig. 1). The total number of patients enrolled in this study was 128,165. The number of patients in the early and delayed surgery groups was 43,928 (34%) and 84,237 (66%), respectively.

Factor setting

First, the LOS data of all patients were collected. Then, the multiple factors that can potentially affect postoperative LOS were ascertained. These included the following: patient details such as type of fracture, surgical procedure, sex, age, body mass index (BMI), and comorbidities at admission like diabetes mellitus, dementia, pneumonia, or osteoporosis; admission details such as the use of an ambulance, admission to a university hospital, application of a regional clinical pathway, and introduction from another hospital; postoperative details such as days until the start of rehabilitation, as well as complications like anaemia, need of blood transfusion, dislocation of bipolar head or artificial hip joint, surgical site infection, deep vein thrombosis, pulmonary embolism, strokes, periprosthetic femoral fracture, bedsore, pneumonia, delirium, and cardiovascular disease.

Statistical analysis

Each factor that can potentially affect postoperative LOS was compared as demographic data between the early operation and delayed operation groups. Then, we analysed the contextual effects of early surgical treatment (within two days of admission) and hospital-level implementation of regional clinical pathways on LOS by employing a multiple logistic regression analysis using the adjusted model. In addition, the effects of sex, age, BMI, comorbidities at admission (diabetes mellitus, dementia, and pneumonia), admission to a university hospital, and introduction from another hospital at admission on LOS were also investigated. All calculations were performed using STATA Release 16.1 (Stata, College Station, TX, USA).

Characteristics of patients in early and delayed surgery groups

The results of the distribution and comparison of patient characteristics between the early (surgery within two days) and delayed surgery groups (surgery over two days) are shown in Table 1. The difference in total LOS (tLOS) in the hospital and postoperative LOS between the early surgery group and the delayed surgery group was six and two days, respectively (tLOS: 22 vs. 28 [early vs. delayed], p < 0.001; postoperative LOS: 21 vs. 23 days, p < 0.001). The early surgery group had more cases of peritrochanteric fractures (57% vs. 43%, p < 0.001) and internal fixation than the delayed surgery group (74% vs. 55%, p < 0.001). In contrast, the delayed surgery group had more cases of femoral neck fractures (43% vs. 57%, p < 0.001) and BHA (25% vs. 42%, p < 0.001) or THA (1.2% vs. 3.0%, p < 0.001). The early surgery group showed a lower rate of comorbidities at admission, except for osteoporosis (diabetes, 16% vs. 19%, p < 0.001; dementia, 3.9% vs. 4.2%, p = 0.044; pneumonia, 0.4% vs. 1.0%, p < 0.001; osteoporosis, 12% vs. 11%, p = 0.012). In addition, the early surgery group used more ambulances at admission (62% vs. 61%, p < 0.001). Interestingly, patients in the delayed surgery group experienced more hospitalizations in university hospitals than those in the early surgery group (4.5% vs 5.5%, p < 0.001). In addition, the early surgery group utilized more regional clinical pathways and had introductions from other hospitals (using a regional clinical pathway, 76% vs. 74%, p < 0.001; introduction from another hospital, 42% vs. 40%, p < 0.001).

Table 1

Distribution and comparison between patient characteristics of early and delayed operation groups.
Variables	Early operation (n = 43,928; 34%)	Delayed operation (n = 84,237; 66%)	P-value
Total length of hospital stay, days (SD)	22 (16–36)	28 (21–45)	< 0.001
Length of stay after surgery, days (SD)	21 (15–34)	23 (16–39)	< 0.001
Diagnosis, yes, n (%)
Femoral neck fracture	18,701 (43%)	47,707 (57%)	< 0.001
Peritrochanteric fracture	25,227 (57%)	36,530 (43%)	< 0.001
Surgical procedure, yes, n (%)
Open reduction and internal fixation	32,660 (74%)	46,682 (55%)	< 0.001
Bipolar hip arthroplasty	10,756 (25%)	35,038 (42%)	< 0.001
Total hip arthroplasty	512 (1.2%)	2,517 (3.0%)	< 0.001
Sex, women, n (%)	34,029 (78%)	64,198 (76%)	< 0.001
Age, years, mean (SD)	86 (79–90)	85 (78–90)	< 0.001
BMI, kg/m², mean (SD)	20.4 (18.1–22.8)	20.4 (18.1–22.9)	< 0.001
Comorbidity at admission, yes, n (%)
Diabetes mellitus	6,972 (16%)	15,941 (19%)	< 0.001
Dementia	1,722 (3.9%)	3,499 (4.2%)	0.044
Pneumonia	191 (0.4%)	827 (1.0%)	< 0.001
Osteoporosis	5,172 (12%)	9,519 (11%)	0.012
Ambulance use, yes, n (%)	27,342 (62%)	51,209 (61%)	< 0.001
Admission to a university hospital, yes, n (%)	2,139 (4.5%)	5,050 (5.5%)	< 0.001
Use of regional clinical pathway, yes, n (%)	36,077 (76%)	67,266 (74%)	< 0.001
Introduction from another hospital on admission, yes, n (%)	19,906 (42%)	36,831 (40%)	< 0.001
Postoperative days until rehabilitation starts, days	1.0 (1.0–2.0)	1.0 (1.0–1.0)	< 0.001
n: sample size, SD: standard deviation

Postoperative complications in early and delayed surgery groups

The details of postoperative complications are shown in Table 2. The early surgery group showed significantly lower rates of complications like surgical site infection, deep vein thrombosis (DVT), pneumonia, and cardiovascular disease (p < 0.001). However, the incidence rates of anaemia and blood transfusion were significantly higher in the early surgery group (anaemia: 12% vs. 8.8%, p < 0.001; blood transfusion: 42% vs. 38%, p < 0.001).

Table 2

Postoperative complications
Complications	Early operation (n = 43,938; 34%)	Delayed operation (n = 84,237; 66%)	P-value
Anaemia	5,255 (12%)	7,410 (8.8%)	< 0.001
Blood transfusion	18,264 (42%)	31,634 (38%)	< 0.001
Bipolar head or artificial hip joint dislocation	60 (0.1%)	132 (0.2%)	0.4
Surgical site infection	356 (0.8%)	834 (1.0%)	0.001
Deep vein thrombosis	1,649 (3.8%)	3,832 (4.5%)	< 0.001
Pulmonary embolism	94 (0.2%)	275 (0.3%)	< 0.001
Strokes	271 (0.6%)	524 (0.6%)	0.94
Periprosthetic femoral fracture	38 (0.1%)	102 (0.1%)	0.09
Bedsore	38 (0.1%)	102 (0.1%)	0.09
Pneumonia	416 (0.9%)	1,076 (1.3%)	< 0.001
Delirium	987 (2.2%)	1,863 (2.2%)	0.69
Cardiovascular disease	1,652 (3.8%)	4,072 (4.8%)	< 0.001
n: sample size

Factors associated with LOS among hip fracture patients

The results of the association of variables with postoperative LOS, obtained from logistic regression analysis using the adjusted model, are shown in Table 3. Factors such as comorbidity at admission (diabetes mellitus and pneumonia), admission to a university hospital, and introduction from another hospital at admission were significantly associated with postoperative LOS. After adjusting for these factors, early surgery and application of the regional clinical pathway significantly reduced postoperative LOS by 2.58 (p < 0.001) and 8.06 (p < 0.001) days, respectively. Furthermore, admission to a university hospital and introduction from another hospital at admission significantly reduced postoperative LOS by 5.68 and 5.00 (p < 0.001), respectively.

Table 3

Multilevel regression analysis of length of stay after operation.
Variables	Coefficient	SE	95% CI		P-value
Operation within 2 days	-2.58	0.12	-2.81	-2.34	< 0.001
Using a regional clinical pathway	-8.06	0.13	-8.32	-7.80	< 0.001
Sex, women	-0.44	0.14	-0.71	-0.17	0.001
Age	0.12	0.01	0.11	0.13	< 0.001
BMI, kg/m2 (vs ༞= 18.5, < 25)	0.06	0.01	0.04	0.09	< 0.001
Comorbidity
Diabetes mellitus	1.67	0.15	1.37	1.96	< 0.001
Dementia	-1.18	0.29	-1.74	-0.61	< 0.001
Pneumonia	0.48	0.64	-0.79	1.74	0.458
Admission to university hospital	-5.68	0.26	-6.19	-5.17	< 0.001
Introduction from another hospital at admission	-5.00	0.12	-5.22	-4.77	< 0.001
SE: standard error, CI: confidence interval

We found that early surgery within two days of hospitalization, which is performed in a third of all hip fracture patients, was effective in reducing postoperative LOS by approximately three days. Furthermore, the early surgery group showed a significantly lower incidence of most postoperative complications than the delayed surgery group. In addition, patients in the early surgery group were more frequently diagnosed with peritrochanteric fracture and underwent ORIF. Notably, our results showed that using a regional clinical pathway to treat these patients had a greater advantage in reducing LOS than performing early surgical treatment. As shown in Table 3, early surgical treatment and use of regional clinical pathways decreased the postoperative LOS by 2.58 and 8.06 days, respectively.

Difference in patient characteristics between early and delayed operation group

Our data showed that the early surgery group had fewer comorbidities upon admission. In the early surgery group, patients were diagnosed with peritrochanteric fracture and underwent more ORIF procedures, whereas the delayed group patients were diagnosed with femoral neck fracture and underwent more BHA or THA. However, it was surprising that the number of patients in the delayed surgery group was twice that of the early surgery group, even though it is well known that early surgery is preferable. Since internal fixation for intertrochanteric femur fractures is less invasive and has a better prognosis than BHA and THA [16], it is believed that the surgery was planned early after the injury. However, it is sometimes difficult to perform early surgery in hip fracture patients because of their comorbidities and poor general conditions. A study investigated the impact of factors contributing to delayed hip fracture surgery on one-year mortality rates, and it revealed that the patients with underlying logistical concerns (such as unavailability of operating rooms and surgeons or sufficient time in the operating room, as well as admission on weekends or holidays) showed a significantly higher incidence of postoperative complications and a higher one-year mortality rate. Thus, it was recommended that the type of surgery and the timing should be determined based on each patient’s general condition. Logistic concerns should not be the reason for delaying surgery [17].

Difference in postoperative complications between early and delayed surgery groups

In our study, the early surgery group showed remarkably fewer postoperative complications, except anaemia, compared to the delayed surgery group.

This result was consistent with those of previous studies that investigated the association between surgery conducted within 48 hours and postoperative complications among hip fracture patients [18–20]. There is a consensus that early surgery for hip fracture can reduce most postoperative complications and even mortality [21]. A lower postoperative incidence of complications contributes to shortened LOS after surgery. Along with LOS, a waiting time of more than 24 hours for hip fracture surgery is also related to the increase in medical costs [22].

AS mentioned earlier, the early surgery group in this study showed a remarkably higher incidence of anaemia and blood transfusion. To our knowledge, very few studies have compared the incidence of anaemia and blood transfusion between the early and delayed surgery groups among hip fracture patients. A large amount blood loss among hip fracture patients often occurs immediately after injury and before surgery. The average frequency of blood loss is greater in peritrochanteric fractures than in femoral neck fractures [23]. Therefore, it can be assumed that the early surgery group had more cases of anaemia and blood transfusion. Bian et al. [24] investigated the influence of preoperative risk factors on postoperative blood transfusion after hip fracture surgery and revealed that older age, general anaesthesia, low preoperative haemoglobin, and non-use of tranexamic acid were independently involved. Therefore, clinicians should be aware of the optimal use of blood transfusion for hip fracture patients, depending on their general condition and potential risk factors.

In this study, the delayed surgical group showed a significantly higher incidence of DVT. Song et al. [25] reported that delayed hip fracture surgery was a risk factor for preoperative DVT, and most patients who were diagnosed with DVT after surgery had already developed thrombus before surgery. Zhang et al. [26] investigated the incidence of DVT in the lower extremities before and after hip fracture surgery. They reported that the number of days between fracture and operation, amount of blood loss, development of venous thrombosis at admission, and presence of coronary heart disease were independent risk factors of postoperative DVT. Fu et al. [27] conducted a similar study and reported that compared with BHA and THA, blood loss was an independent risk factor while ORIF was an independent protective factor for postoperative DVT. Although the early surgery group in our study showed a higher incidence of anaemia, the findings of these studies are consistent with our assumptions.

Contribution of early surgery and other factors in LOS reduction

Our results showed that early surgery within two days of admission shortened the postoperative LOS by 2.58 days and reduced most of the postoperative complications, except anaemia and blood transfusion. Therefore, early surgery for hip fracture patients within two days is highly recommended. Additionally, it was revealed that concomitant diabetes mellitus or pneumonia increased LOS, which suggested that preoperative management of these comorbidities is crucial. Lizaur-Utrilla et al. [17] suggested that a waiting time of more than two days was not related to higher mortality rate or development of complications if the time was used to stabilize active comorbidities in patients upon admission.

Additionally, clinical pathways and introduction from another hospital at admission also reduced postoperative LOS for hip fracture patients by 8.06 days and 5.00 days, respectively. Takahashi et al. [28] investigated the factors associated with LOS after hip fracture surgery and reported that the admission to a high-volume surgery hospital was a factor that contributes to the reduction of LOS. Fujino et al. [29] also investigated the relationship between LOS and the implementation of regional clinical pathways among stroke patients. They reported that use of regional clinical pathways among those patients at hospital and patient level had a great impact on the reduction of LOS by 9.1 days and 7.2 days, respectively. Therefore, sharing a unified postoperative protocol by implementing the regional clinical pathways leads to effective utilization of hospital beds.

Limitations

This study has some limitations. First, since we utilized the DPC database for this study, our data may not present sufficient information for all patients with hip fractures. There might have been a selection bias. In addition, the DPC database only includes the patient’s data from acute care hospitals. Therefore, patient data post-discharge were not obtained. Further studies must be conducted to assess the impact of early surgical treatment and the use of regional clinical pathways throughout the treatment of hip fracture patients.

Although the clinical guidelines recommended early surgery for hip fracture patients, the number of patients in the delayed surgery group was twice that of the early surgery group. In addition, early surgery group had more peritrochanteric fracture cases, whereas delayed surgery group had more femoral neck fracture cases. This study revealed that early surgery for hip fracture patients within two days after admission reduced postoperative LOS and postoperative complications. Moreover, the implementation of regional clinical pathways to treat these patients had a greater impact on reducing postoperative LOS. The findings of this study will help acute care givers tend to patients with hip fractures more efficiently and reduce admission processing time as well as the length of hospital stay, which can be mentally and economically taxing especially for older patients.

ADL; activities of daily living, DPC; Diagnosis Procedure Combination, ORIF; open reduction and internal fixation, BHA; bipolar hip arthroplasty, THA; total hip arthroplasty, LOS; length of stay, BMI; body mass index, DVT; deep vein thrombosis

Ethics approval and consent to participate: The study followed the principles of the Declaration of Helsinki and its later amendments. The study protocol was approved by the Ethics Committee of Medical Care and Research of the University of Occupational and Environmental Health, Japan (approval no. R1-067). Because of the anonymous nature of the data, the requirement for informed consent was waived.

Consent for publication: Not applicable

Availability of data and materials: The datasets generated and analysed during the current study are not publicly available due to restrictions on the Japanese DPC database which is managed by the Ministry of Health, Labor and Welfare, but are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This work was supported by a Grant-in-Aid for Scientific Research [grant numbers (C) 20K09421] from the Japan Society for the Promotion of Science (JSPS) to HS.

Authors’ contributions: HN, HS, KT, KM, SM, and AS conceived the idea and designed the study. KT, KM, KF, and SM collected the relevant data. HN, KT, MK, and YY prepared the figure and tables. KT and KM performed the statistical analyses. All the authors interpreted the data and contributed to preparation of the manuscript. HN, SU, and EN wrote the initial draft of the manuscript, and completed the final version. The author(s) read and approved the final manuscript.

Acknowledgments: We would like to thank Editage (www.editage.com) for English language editing.

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No competing interests reported.

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Early surgical treatment using regional clinical pathways reduces the length of postoperative hospitalization in hip fracture patients: A retrospective analysis using the Japanese Diagnosis Procedure Combination database

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Abstract

Figures

Background

Methods

Data sources

Data collection

Factor setting

Statistical analysis

Results

Characteristics of patients in early and delayed surgery groups

Postoperative complications in early and delayed surgery groups

Factors associated with LOS among hip fracture patients

Discussion

Difference in patient characteristics between early and delayed operation group

Difference in postoperative complications between early and delayed surgery groups

Contribution of early surgery and other factors in LOS reduction

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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