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Background: Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals., Methods: We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay., Results: For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1-6.1), 12.2% (95% CI 10.3-14.2), and 22.0% (95% CI 17.7-26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay., Conclusion: Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

Objective: We describe steps to operationalise a published conceptual framework for a contiguous hospitalisation episode using acute care hospital discharge abstracts. We then quantified the degree of bias induced by a first abstract episode, which does not account for hospital transfers., Design: Retrospective observational study., Setting: All acute care hospitals in nine Canadian provinces., Participants: We retrieved acute hospitalisation discharge abstracts for 189 448 patients aged 65 years and older admitted to acute care with hip fracture between 2003 and 2013., Primary and Secondary Outcome Measures: The percentage of patients treated surgically, delayed to surgery (defined as two or more days after admission) and dying, between contiguous hospitalisation episodes and the first abstract episodes of care., Results: Using contiguous hospitalisation episodes, 91.6% underwent surgery, 35.7% were delayed two or more days after admission and 6.7% died postoperatively, whereas, using the first abstract only, these percentages were 83.7%, 32.5% and 6.5%, respectively., Conclusion: We demonstrate that not accounting for hospital transfers when evaluating the association between surgical timing and death underestimates reporting of the percentage of patients treated surgically and delayed to surgery by 9%, and the percentage who die after surgery by 3%. Researchers must be aware of this potential and avoidable bias as, depending on the purpose of the study, erroneous inferences may be drawn., Competing Interests: Competing interests: The authors declare that (1) Boris Sobolev, Pierre Guy and the Collaborative have received grants from the Canadian Institutes of Health Research related to this work. (2) Pierre Guy also receives funding from the Natural Sciences and Engineering Research Council of Canada, the Canadian Foundation for Innovation and the British Columbia Specialists Services Committee for work around hip fracture care not related to this manuscript. He has also received fees from the BC Specialists Services Committee (for a provincial quality improvement project on redesign of hip fracture care) and from Stryker Orthopedics (as a product development consultant). He is a board member and shareholder in Traumis Surgical Systems Inc. and a board member for the Canadian Orthopedic Foundation. He also serves on the speakers’ bureaus of AO Trauma North America and Stryker Canada. (3) Suzanne Morin reports research grants from Amgen Canada, and from Merck, personal fees from Amgen Canada outside the submitted work., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay., Methods: We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram., Results: Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%)., Interpretation: Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons., Competing Interests: Competing interests: Boris Sobolev, Pierre Guy and the Collaborative report receiving grants from the Canadian Institutes of Health Research related to this work. Pierre Guy reports receiving grants from the Natural Sciences and Engineering Research Council of Canada, the Canadian Foundation for Innovation and the British Columbia Specialists Services Committee for work regarding hip fracture care, outside the submitted work. He has also received fees from the BC Specialists Services Committee (for a provincial quality improvement project on redesign of hip fracture care) and from Stryker Orthopaedics (as a product development consultant), outside the submitted work. He is a board member and shareholder in Traumis Surgical Systems Inc. and a board member for the Canadian Orthopaedic Foundation. He also serves on the speakers’ bureaus of AOTrauma North America and Stryker Canada. Suzanne Morin reports research grants from Amgen Canada, outside the submitted work. Jason Kim and Lisa Kuramoto report receiving grants from the Canadian Institutes of Health Research, during the conduct of the study. No other competing interests were declared., (© 2018 Joule Inc. or its licensors.)

The extent of Canadian provincial variation in hip fracture surgical timing is unclear. Provinces performed a similar proportion of surgeries within three inpatient days after adjustment. Time to surgery varied by timing of admission across provinces. This may reflect different approaches to providing access to hip fracture surgery., Introduction: The aim of this study was to compare whether time to surgery after hip fracture varies across Canadian provinces for surgically fit patients and their subgroups defined by timing of admission., Methods: We retrieved hospitalization records for 140,235 patients 65 years and older, treated surgically for hip fracture between 2004 and 2012 in Canada (excluding Quebec). We studied the proportion of surgeries on admission day and within 3 inpatient days, and times required for 33%, 66%, and 90% of surgeries across provinces and by subgroups defined by timing of admission. Differences were adjusted for patient, injury, and care characteristics., Results: Overall, provinces performed similar proportions of surgeries within the recommended three inpatient days, with all provinces requiring one additional day to perform the recommended 90% of surgeries. Prince Edward Island performed 7.0% more surgeries on admission day than Ontario irrespective of timing of admission (difference = 7.0; 95% CI 4.0, 9.9). The proportion of surgeries on admission day was 6.3% lower in Manitoba (difference = - 6.3; 95% CI - 12.1, - 0.6), and 7.7% lower in Saskatchewan (difference = - 7.7; 95% CI - 12.7, - 2.8) compared to Ontario. These differences persisted for late weekday and weekend admissions. The time required for 33%, 66%, and 90% of surgeries ranged from 1 to 2, 2-3, and 3-4 days, respectively, across provinces by timing of admission., Conclusions: Provinces performed similarly with respect to recommended time for hip fracture surgery. The proportion of surgeries on admission day, and time required to complete 33% and 66% of surgeries, varied across provinces and by timing of admission. This may reflect different provincial approaches to providing access to hip fracture surgery.

Unlabelled: We determined age-standardized first hip fracture rates in British Columbia between 1990 and 2004. We found sex and fracture type rates in keeping with previous reports and that fracture rates have decreased approximately 18% overall in both men and women., Introduction: To determine whether there have been changes in the age-, sex-, and subtype-specific first hip fracture rates in Canadian province of British Columbia (BC) between 1990 and 2004., Methods: Records of all persons aged 60 years and older hospitalized with hip fractures in BC between 1985 and 2004 were obtained from the Canadian Institute for Health Information Discharge Abstract Database. Only the first hip fracture records were included, and fractures likely due to causes other than trauma were excluded. Age- and sex-specific rates were calculated using population denominators from Statistics Canada and direct standardization was used. Age-standardized rates allowed for comparison across years with adjustment for age distribution., Results: There were 41,990 records of first hip fracture included, and 73% were in women. Trends in age-specific rates by fracture type were similar to previous reports. Between 1990 and 2004, there has been an age-adjusted 18% decrease in first hip fracture rates in women, and 19% decrease in first hip fracture rates in men. The decrease was statistically significant in femoral neck fractures in women, but not in men., Conclusions: There has been a decrease in age-adjusted hip fracture rates in BC between 1990 and 2004, which is in contrast to previous projections for hip fracture rates in Canada.

Unlabelled: A comprehensive review of literature was conducted to investigate variation in hip fracture incident rates around the world. The original crude incidence rates were standardized for age and sex for comparability. After standardization, the highest rates of hip fracture were found in Scandinavia and the lowest rates in Africa., Introduction: This study was conducted to investigate the geographic trends of the incidence of osteoporotic hip fractures through a comprehensive review of literature., Methods: Studies were identified for inclusion in the review by searching the MEDLINE database via PubMed and applying strict inclusion and exclusion criteria. Age-specific incidence rates were extracted from the articles, and in order to provide a common platform for analysis, we used directly age-standardized and age-sex-standardized rates (using the 2005 United Nations estimates of the world population as standard) to complete the analysis., Results: Forty-six full text articles spanning 33 countries/regions were included in the review. For ease of comparison, the results were analyzed by geographic regions: North America, Latin America, Scandinavia, Europe (excluding Scandinavia), Africa, Asia, and Australia. The highest hip fracture rates were found in Scandinavia and the lowest in Africa. We found comparable rates from countries in North America, Australia, and Europe outside of Scandinavia. The diverse makeup of the Asian continent also resulted in quite variable hip fracture rates: ranging from relatively high rates in Iran to low rates, comparable to those from Africa, in mainland China., Conclusions: Given the aging of populations globally, and in the industrialized countries specifically, hip fractures will become a progressively larger public health burden. The geographic trends observed in hip fracture incidence rates can provide important clues to etiology and prevention.

An association between inclement weather and hip fractures has been documented, but specific subgroups of the population at particular risk have not been identified. We obtained information that included hospitalization data on all hip fractures in Montreal from 1982 to 1992, and meteorologic data on the amount of snow, rain, and freezing rain and the temperature on each day of study. We used a cross-level design to examine the association between the rate of hip fractures and the meteorologic conditions on the day of the accident in both sexes and five age strata. There were a total of 18,455 hip fractures over the 4,018-day study period. We found a cyclical pattern in occurrence of hip fractures, with the peak occurring in mid-December among women and the first week of January among men. The pattern was less pronounced among women than men, with peak-to-trough ratios of 1.2 and 1.4, respectively. Days with lower temperatures, snow, and freezing rain were associated with increased rates of hip fracture. The meteorologic condition carrying the greatest risk was freezing rain. The association between inclement weather and hip fractures was stronger among younger persons, both women and men. After adjusting for meteorologic variables, there remained increases in winter of 5% among women and 12% among men. The residual effect of winter may be related to cold temperatures or due to an accumulation of ice and snow even on fine days. Other possible mechanisms to explain the residual effect of winter include slower reaction times and winter bone loss, both of which could affect indoor as well as outdoor falls.

Two distinct subtypes of hip fracture, transcervical and pertrochanteric, can be distinguished on the basis of the anatomical location of the injury. While the epidemiology of hip fractures has been well described, typically, little or no distinction is made between these subtypes. The objective of this study was to compare and contrast age- and sex-specific rates of transcervical and pertrochanteric fractures in Quebec, Canada. The data for this study were obtained from a database containing records of all persons discharged from all hospitals in Quebec from 1981 to 1992. Rates of hip fractures were calculated by using the population aged 50 years and older as the denominator, and changes in rates over time were assessed using Poisson regression. There were no statistically significant trends in the changes in rates over time (i.e., 95 percent confidence intervals overlapped the null value). Among women below age 70 years, transcervical fractures were more common, whereas among older women, pertrochanteric fractures predominated. Among men, pertrochanteric fractures predominated at all ages. There was a marked seasonal variation in the occurrence of all hip fractures combined: Compared with the summer months, the relative risk of all hip fractures during the winter was 1.32 (95 percent confidence interval 1.28-1.36). The results of this study indicate that the two subtypes of hip fracture, transcervical and pertrochanteric, have different patterns of occurrence, suggesting different risk factor profiles. Clearly, a multidisciplinary research approach is needed before it will be possible to untangle the complex relation between the metabolic processes occurring at the level of the individual and the distribution of the disease in the population.

A matched case-control study was carried out to identify risk factors for fractures due to falls. All falls that occurred at a rehabilitation hospital from 1981 to 1988 were identified and classified as index falls (falls resulting in fractures) or referent falls (falls not resulting in fractures). For each of the 94 index falls, four referent falls were chosen at random (n = 376) from all other falls occurring in the same four week period. The average age of the individuals sustaining the index fall was 76.8 +/- 10.4 years, and 68% were female; in contrast, the average age of the individuals sustaining the referent fall was 72.0 years (+/- 13.2), and 32% were female. Fractures of the hip predominated (n = 40; 42.6%) and fractures of the ribs were the second most prevalent (n = 20; 21.4%). Fractures most often ensured from a fall from the upright position. Of the 24 variables considered in the conditional logistic regression model, advanced age, being female, being ambulatory, experiencing disorientation, use of vitamin supplements, and use of antiulcer medications were significantly associated with the risk of a fracture. Thus, because fractures are potentially life-threatening, strategies to prevent falls should be targeted especially towards those who are at risk to sustain a fracture from a fall. However, to be compatible with rehabilitation goals, the preventive strategies must strike a balance between the achievement of functional autonomy and patient safety.