Inequalities in use of total hip arthroplasty for hip fracture: population based study

Abstract

Objectives To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities.Design Observational cohort study using the National Hip Fracture Database (NHFD).Setting All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland.Participants Patients within the national database (all aged ≥60) who received operative treatment for a non-pathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015.Main outcome measures Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE).Results 114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780)received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98).Conclusions There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital.

Association between socioeconomic deprivation and surgical complications in adults undergoing ankle fracture fixation: a population-based analysis

“…Therefore, the purported risk of infection or amputation should not preclude a socially deprived patient from operative management of an unstable ankle fracture. Similar to what has been reported previously in the literature on hip fractures, 7 our data also support the existence of some inequalities in provision of care for more deprived patients. More deprived patients were less likely to undergo removal of hardware; the reason is unclear, but may reflect a lack of follow-up for more deprived patients or a reluctance among surgeons to offer those patients a second surgery.…”

A process evaluation of the WHiTE Two trial comparing total hip arthroplasty with and without dual mobility component in the treatment of displaced intracapsular fractures of the proximal femur

“…As part of our process evaluation we have explored possible patterns of clinical decision making that might explain which patients are offered THA. 15 …”

Mortality by Timing of Hip Fracture Surgery

“…[58][59][60] The presence of chronic conditions 66,67 and postoperative complications 68 also depends on age at admission, with older patients presenting with more chronic conditions and complications than younger patients. Surgery type depends on the fracture type, with arthroplasty being the treatment of choice for femoral neck fractures 69 and fixation being the treatment of choice for intertrochanteric fractures. 70 The time of admission depends on the need for transfers before definitive care, because patients who are transferred are more likely to be admitted late in the day than patients who are admitted directly.…”

“…First, age produces variation in time to surgery through fitness for surgery, 49 and also produces variation in postoperative in-hospital death through chronic conditions and complications. [66][67][68] Second, fracture type produces variation in time to surgery through surgery type, 69,70 and also produces variation in postoperative in-hospital death. [58][59][60] Figure 2, thus highlights four factors that produces variation in time to surgery and postoperative in-hospital death: hospital type, surgery type, age at admission, and fracture type.…”