UNLABELLED

Despite a recent reimbursement policy promoting early surgery for hip fractures in Japan, more than half of elderly patients experienced delays. Referral refusals, weekend admissions, comorbidity-related evaluations, and arthroplasty were key predictors. System-level reforms are needed to improve timely surgical access in Japan's aging population.

PURPOSE

To identify pre-admission and post-admission factors associated with surgical delays for hip fractures in elderly patients, despite the recent implementation of the Japanese Ministry of Health, Labour and Welfare (MHLW) reimbursement policy incentivizing early surgery within 48 h.

METHODS

This retrospective cohort study included 366 patients aged ≥ 75 years who underwent surgery for hip fractures at a single acute-care hospital between January 2022 and December 2023. Patients were classified into early surgery (≤ 48 h) and delayed surgery (> 48 h) groups. Time to surgery was divided into pre-admission and post-admission intervals. Variables analyzed included age, sex, residence, referral refusal, admission day of the week, preoperative multi-specialty consultation, anticoagulant use, fracture type, and surgical procedure. Multivariate logistic regression identified independent predictors of delay.

RESULTS

Of all patients, 48.9% underwent early surgery. The delayed group had significantly longer pre- and post-admission times. Four factors were independently associated with delay: referral refusal (p = 0.027), admission later in the week (p = 0.004), preoperative multi-specialty consultation (p = 0.001), and arthroplasty rather than internal fixation (p = 0.028). In contrast, age, sex, residence, fracture type, and anticoagulant use were not significantly associated. Postoperative hospital stay was paradoxically longer in the early surgery group, primarily due to differences in discharge readiness between nursing home residents and community dwellers.

CONCLUSION

Despite financial incentives, surgical delays persist due to both pre- and post-admission factors. System-level reforms-including improved referral systems, coordinated weekend surgical access, streamlined workflows, and adequate implant availability-are needed to enhance the effectiveness of early surgery initiatives in Japan's aging population.