Effects of Capacity-Related Delay to Hip Fracture Surgery on Mortality: A Matched-Cohort Study

Timely surgery is emphasized in hip fracture care. Prior studies examining this have failed to distinguish adequately between delays for medical optimization and those due to limited operative capacity, introducing important confounders. This study aimed to determine the impact of capacity-related delays on mortality after a hip fracture in older individuals, as well as the factors moderating these effects.

This retrospective cohort study involved patients treated in a U.K. teaching hospital from January 2020 to June 2024. Primary outcomes were mortality at 30 and 365 days. The exposure of interest was capacity-delayed hip fracture surgery, defined as operative anesthesia for hip fracture surgery occurring >36 hours after emergency department presentation. Patients aged ≥65 years with an operatively managed fracture of the native proximal femur were included. Patients were excluded if surgery was delayed for medical reasons. Multivariable logistic regression was used to examine mortality risk factors, and propensity-score matching was performed on the basis of covariates affecting mortality and survival analysis.

Of 3,094 screened patients, 2,358 were eligible. Mortality status was available for 96.9% of patients at 365 days. One thousand and eighty-seven (46%) received timely surgery while 1,271 (54%) experienced capacity-related delay. After propensity-score matching, the median age was 85 years (interquartile range, 78 to 90 years), 73% were female, and 98% were White. Capacity delay was associated with a greater hazard of 365-day mortality (hazard ratio [HR] = 1.37, 95% confidence interval [CI]: 1.15 to 1.63), and the hazard was most pronounced in the first 30 days (HR = 1.71, 95% CI: 1.11 to 2.65). Shorter-term (30-day) mortality in patients with a higher Clinical Frailty Scale score (>4) was most affected by delay (odds ratio [OR] = 1.76, 95% CI: 1.06 to 3.02), while effects on less frail patients were not significant.

Capacity-related delays in hip fracture surgery were associated with greater mortality after accounting for patient-related risk factors. This study overcomes a key confounder by isolating capacity-related delay. The results may support prioritizing timely hip fracture surgery for more vulnerable patients.

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.