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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Health Services Research 1/2012

Timing of surgery for hip fracture and in-hospital mortality: a retrospective population-based cohort study in the Spanish National Health System

BMC Health Services Research > Ausgabe 1/2012
Julián Librero, Salvador Peiró, Edith Leutscher, Juan Merlo, Enrique Bernal-Delgado, Manuel Ridao, Natalia Martínez-Lizaga, Gabriel Sanfélix-Gimeno
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6963-12-15) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

JL, SP and EBD are guarantors of the study, had full access to all the data, and take responsibility for the integrity and the accuracy of the analysis and results. All authors contributed to the conception and the design of the article. NML acted as data-manager for the study. JL, SP, EL and GSG contributed to the study analysis. JL, SP, EBD and JM interpreted the results, and SP, GSG and EBD drafted the article. All the authors read and approved the final manuscript.



While the benefits or otherwise of early hip fracture repair is a long-running controversy with studies showing contradictory results, this practice is being adopted as a quality indicator in several health care organizations. The aim of this study is to analyze the association between early hip fracture repair and in-hospital mortality in elderly people attending public hospitals in the Spanish National Health System and, additionally, to explore factors associated with the decision to perform early hip fracture repair.


A cohort of 56,500 patients of 60-years-old and over, hospitalized for hip fracture during the period 2002 to 2005 in all the public hospitals in 8 Spanish regions, were followed up using administrative databases to identify the time to surgical repair and in-hospital mortality. We used a multivariate logistic regression model to analyze the relationship between the timing of surgery (< 2 days from admission) and in-hospital mortality, controlling for several confounding factors.


Early surgery was performed on 25% of the patients. In the unadjusted analysis early surgery showed an absolute difference in risk of mortality of 0.57 (from 4.42% to 3.85%). However, patients undergoing delayed surgery were older and had higher comorbidity and severity of illness. Timeliness for surgery was not found to be related to in-hospital mortality once confounding factors such as age, sex, chronic comorbidities as well as the severity of illness were controlled for in the multivariate analysis.


Older age, male gender, higher chronic comorbidity and higher severity measured by the Risk Mortality Index were associated with higher mortality, but the time to surgery was not.
Additional file 1: Charlson Index. adaptation of the Charlson Comorbidity index for administrative databases. (DOC 48 KB)
Additional file 2: Risk Mortality Index. adaptation of the Majumdar et al. Risk Mortality Index for hip fracture. (DOC 46 KB)
Additional file 3: Hospital level approach. Scatter plot between the proportion of delayed patients by hospital and the inhospital mortality rate. (DOC 382 KB)
Additional file 4: Multilevel approach. Variations in in-hospital mortality between hospitals. A multi-level approach. (DOC 2 MB)
Additional file 5: Instrumental variable approach. Instrumental variable analysis. (DOC 106 KB)
Authors’ original file for figure 1
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