髋部骨折患者手术延迟的原因和后果：一项队列研究。

Causes and effects of surgical delay in patients with hip fracture: a cohort study.

机构信息

Hospital General Universitario Gregorio Marañón, Madrid, Spain.

出版信息

Ann Intern Med. 2011 Aug 16;155(4):226-33. doi: 10.7326/0003-4819-155-4-201108160-00006.

DOI:10.7326/0003-4819-155-4-201108160-00006

PMID:21844548

Abstract

BACKGROUND

The clinical effect of surgical delay in older patients with hip fracture is controversial. Discrepancies among study findings may be due to confounding that is caused by the reason for the delay or a differential effect on patient risk subgroups.

OBJECTIVE

To assess the effect of surgical delay on hospital outcomes according to the cause of delay.

DESIGN

Prospective cohort study.

SETTING

A hip fracture unit in a university hospital in Spain.

PATIENTS

2250 consecutive elderly patients with hip fracture.

MEASUREMENTS

Time to surgery, reasons for surgical delay, adjusted in-hospital death, and risk for complications.

RESULTS

Median time to surgery was 72 hours. Lack of operating room availability (60.7%) and acute medical problems (33.1%) were the main reasons for delays longer than 48 hours. Overall, rates of hospital death and complications were 4.35% and 45.9%, respectively, but were 13.7% and 74.2% in clinically unstable patients. Longer delays were associated with higher mortality rates and rates of medical complications. After adjustment for age, dementia, chronic comorbid conditions, and functionality, this association did not persist for delays of 120 hours or less but did persist for delays longer than 120 hours (P = 0.002 for overall time effect on death and 0.002 for complications). The risks were attenuated after adjustment for the presence of acute medical conditions as the cause of the delay (P = 0.06 for time effect on mortality and 0.31 on medical complications). Risk for urinary tract infection remained elevated (odds ratio, 1.54 [95% CI, 0.99 to 2.44]). No interaction between delay and age, dementia, or functional status was found.

LIMITATION

This was a single-center study without postdischarge follow-up.

CONCLUSION

The reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay, although some association between very delayed surgery and worse outcomes persists.

PRIMARY FUNDING SOURCE

None.

摘要

背景

手术延迟对老年髋部骨折患者的临床效果存在争议。研究结果的差异可能是由于延迟的原因引起的混杂因素，或者对患者风险亚组的不同影响。

目的

根据延迟的原因评估手术延迟对住院结局的影响。

设计

前瞻性队列研究。

地点

西班牙一所大学医院的髋部骨折病房。

患者

2250 例连续的老年髋部骨折患者。

测量方法

手术时间、手术延迟的原因、调整后的院内死亡和并发症风险。

结果

中位手术时间为 72 小时。无手术间可用性（60.7%）和急性医疗问题（33.1%）是超过 48 小时的主要延迟原因。总体而言，医院死亡率和并发症发生率分别为 4.35%和 45.9%，但在不稳定的临床患者中分别为 13.7%和 74.2%。延迟时间越长，死亡率和医疗并发症发生率越高。在调整年龄、痴呆、慢性合并症和功能后，这种关联在 120 小时或更短的延迟中没有持续存在，但在超过 120 小时的延迟中持续存在（死亡的总体时间效应的 P 值=0.002，并发症的 P 值=0.002）。在调整延迟原因是急性医疗状况后，这种风险减弱（死亡率时间效应的 P 值=0.06，医疗并发症的 P 值=0.31）。尿路感染的风险仍然升高（比值比，1.54 [95%置信区间，0.99 至 2.44]）。未发现延迟与年龄、痴呆或功能状态之间存在交互作用。