Clinical Effects of Surgical Delay in Older Patients with Intertrochanteric Fractures: Analysis from the National Inpatient Sample Database

Clinical Effects of Surgical Delay in Older Patients with Intertrochanteric Fractures: Analysis from the National Inpatient Sample Database | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Clinical Effects of Surgical Delay in Older Patients with Intertrochanteric Fractures: Analysis from the National Inpatient Sample Database Zhijie Pan, Yuning Lin, Haitang Deng, Wenjie Feng, Qingfeng Shao, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5295283/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The clinical effect of surgery timing in older patients with intertrochanteric fractures (IFs) is controversial. Our objective was to assess the association between surgery timing and in-hospital mortality and postoperative complications in these patients. In our study, 228,725 patients accepted internal fixation surgery for IFs were obtained from the 2002 to 2014 Nationwide inpatient sample (NIS) database. They were categorized into 3 subgroups according to the time of admission to surgery: early, shorter delays, and longer delays. The prevalence of internal fixation surgery in IFs patients significantly increased over time. Delays in surgery were associated with longer LOS, extra hospital charges, and higher risk of postoperative complications. Rates of in-hospital death were 2.110% and 4.214%, respectively in two delay groups. After adjustment, shorter delays was not associated with in-hospital death (OR: 1.024, CI: 0.953, 1.088;P = 0.520), longer delays was obviously associated with an increased risk of death during hospitalization (OR: 1.547, CI: 1.410, 1.696;P<0.001). Prolonged waiting time for surgery significantly increased the risk of developing adverse events. Therefore, reasonable preoperative optimization and strive for early surgery are necessary. Health sciences/Medical research/Outcomes research Health sciences/Risk factors Figures Figure 1 Figure 2 Introduction Intertrochanteric fractures (IFs) were common in the older population. Worldwide, 4.5 million people are disabled from hip fracture each year, with projections indicating a potential increase to 6.3 million by 2050. 1 ; 2 The IFs, one of the most prevalent types of hip fractures, accounts for approximately 50% of hip fractures 3 and exerts a significant financial burden on healthcare expenses and societal costs worldwide. Surgical treatment utilizing internal fixation, permitting immediate postoperative weight-bearing and reducing complications, is considered the "gold standard technique" for managing such fractures. 4 ; 5 Guidelines on hip fractures management across various countries recommend surgery within 48 hours or even as little as the same day or the time of admission. 6 ; 7 Early surgery will reduce the time patients are exposed to those harmful states 8 ; 9 , which might increase the risk of medical complications and mortality. Numerous institutions schedule these procedures after hours to prompt the execution of such fracture surgeries. 10 ; 11 However, sleep deprivation and fatigue significantly compromise surgeons' neurocognitive abilities, heightening the potential for serious medical mishaps. 12 On the other hand, Patients afflicted with numerous comorbidities frequently reside in a fragile condition, exhibiting clinical signs of diminished physiological resilience, heightened mortality risk, and enhanced sensitivity to stress. 13 Delaying surgery to optimize surgical planning and perioperative management based on the preoperative patient status is a viable approach for improving patient outcomes. The surgery timing for patients with IFs remains a topic of debate. Previous studies[26; 33; 35] on this subject were limited by factors such as small patient populations, which hindered a comprehensive understanding of patient demographics and early surgical outcomes. Therefore, we embarked on an investigation utilizing a database from the United States between 2002 and 2014 to depict the demographics of IFs patients with internal fixation and the surgical delay on clinical outcomes. Materials and Methods Data Source Data were acquired from the National Inpatient Sample (NIS) database, a resource offered by the Healthcare Cost and Utilization Project (HCUP). The NIS stands as the largest all-payer database in the United States, containing discharge data garnered from a strategically selected 20% sample of community hospitals, comprehensively covering 95% of the US population. Each hospitalization record in the NIS database encompasses comprehensive data, spanning patient demographics, hospital characteristics, over 20 distinct diagnosis and procedure categories (defined by the International Classification of Diseases (ninth revision) Clinical Modification (ICD-9-CM)), accompanying comorbidities, length of stay, and the total associated charges. Study Population The study population comprised hospitalizations in the United States from 2002 to 2014 for intertrochanteric fracture that received internal fixation treatment. We included all admissions with a diagnosis code for intertrochanteric fractures (ICD-9-CM codes of 820.21) and a procedure code for internal fixation (ICD-9-CM codes of 79.15, 79.35, 78.55). 17 Patients with missing data, aged less than 60, and undergoing procedures over 7 days were excluded from this study. Subsequently, we categorized the patients into 3 subgroups based on recommended surgical timing 6 ; 7 after admission in the guidelines:1) early (within 24 hours), 2) shorter delay (1 to 2 days), and 3) longer delay (3 to 7 days). The detailed flow can be visualized in Fig. 1 . Study Variable Patient demographics and hospital characteristics were evaluated. Outcome measures such as length of stay (LOS), total hospitalization costs, in-hospital mortality, and postoperative complications were analyzed. We searched the database for postoperative complications before discharge, utilizing the ICD-9-CM diagnostic code. We determined cerebrovascular, cardiovascular, acute renal failure, pulmonary including respiratory failure and pneumonia, venous thromboembolism including deep vein thrombosis and pulmonary embolism, mechanical wound included surgical wound dehiscence and hematoma, systemic complication included septic shock and hemorrhage, post-operative infection, urinary complication, as well as post-operative anemia as in-hospital postoperative complications in IF patients. The specific ICD-9 codes for complications are listed below SUPPLEMENTARY TABLE 1 . Table 1 Demographics of Older Patients Undergoing Internal Fixation For intertrochanteric fractures During Different Surgery Timing. Group Early (N = 56582) Shorter Delay (N = 148910) Longer Delay (N = 23233) P Value Average age (y) (± SD) 82.099 ± 8.577 82.420 ± 8.297 82.018 ± 8.330 < 0.001 Gender (%) < 0.001 Male 25.391 26.086 31.774 Female 74.609 73.914 68.226 Admission type (%) < 0.001 Non-elective admission 95.564 96.512 96.178 Elective admission 4.436 3.488 3.822 RACE (%) < 0.001 White 89.672 87.720 82.082 Black 2.518 3.014 4.722 Hispanic 4.098 5.435 8.462 Asian or Pacific Islander 1.343 1.410 1.756 Native American 0.384 0.350 0.379 Other 1.985 2.071 2.600 Primary expected payer (%) < 0.001 Medicare 89.239 89.924 89.739 Medicaid 1.285 1.545 2.419 Private insurance 7.357 6.605 5.961 Self-pay 0.748 0.647 0.740 No charge 0.049 0.075 0.095 Other 1.322 1.205 1.046 Admission day (%) < 0.001 Monday-Friday 73.695 72.066 70.421 Saturday-Sunday 26.305 27.934 29.579 Location of hospital (%) < 0.001 Rural 14.740 12.792 10.145 Urban 85.260 87.208 89.855 Teaching status of hospital (%) < 0.001 Nonteaching 63.013 61.883 58.451 Teaching 36.987 38.117 41.549 CCI (± SD) 5.140 ± 1.458 5.277 ± 1.503 5.685 ± 1.669 < 0.001 Total comorbidities 2.857 ± 1.738 3.107 ± 1.779 3.686 ± 1.923 < 0.001 Mortality (%) 1.847 2.110 4.214 < 0.001 length of stay (± SD) 4.906 ± 3.332 5.997 ± 3.669 9.594 ± 5.745 < 0.001 Postoperative LOS (± SD) 4.906 ± 3.332 4.740 ± 3.624 5.773 ± 5.557 < 0.001 Total hospitalization costs (USD) (± SD) 40162.789 ± 33646.526 46163.443 ± 37687.854 67894.898 ± 61840.851 < 0.001 CCI: Charlson Comorbidity Index; SD: standard deviation; USD: US dollar Table 2 Incidence of Complications in Older Patients Undergoing internal fixation For Intertrochanteric Fractures. Complication (%) Early Shorter Delay Longer Delay P Value Cerebrovascular 0.599 0.719 1.541 < 0.001 Cardiovascular 2.490 2.872 5.755% < 0.001 Acute renal failure 6.405 7.564 13.395 < 0.001 Pulmonary 5.8 6.8 14.6 < 0.001 Venous thromboembolism 0.746 1.078 2.484 < 0.001 Mechanical wound 0.580 0.517 0.775 < 0.001 Systemic complication 1.166 1.054 0.857 < 0.001 Post-operative infection 0.171 0.248 0.560 < 0.001 Urinary complication, 15.392 18.699 26.045 < 0.001 Post-operative anemia 38.648 35.377 24.302 < 0.001 Table 3 Multivariate Regression Results of Postoperative Complications and Mortality. † Complications Shorter Delay Longer Delay OR ‡ 95%CI P value OR ‡ 95%CI P value Cerebrovascular 1.105 0.975–1.252 0.117 1.921 1.642–2.248 <0.001 Cardiovascular 1.058 0.995–1.125 0.073 1.771 1.637–1.916 <0.001 Acute renal failure 1.032 0.990–1.076 0.138 1.491 1.410–1.577 <0.001 Pulmonary 1.102 1.056–1.149 <0.001 2.035 1.928–2.147 <0.001 Venous thromboembolism 1.318 1.181–1.471 <0.001 2.489 2.178–2.844 <0.001 Mechanical wound 0.865 0.759–0.985 0.029 1.146 0.951–1.382 0.152 Systemic complication 0.901 0.821–0.987 0.026 0.708 0.602–0.832 <0.001 Post-operative infection 1.378 1.100-1.725 0.005 2.489 1.900–3.260 <0.001 Urinary complication 1.236 1.203–1.269 <0.001 1.861 1.791–1.934 <0.001 Post-operative anemia 0.881 0.863–0.901 <0.001 0.513 0.494–0.532 <0.001 Mortality 1.024 0.953,1.100 0.520 1.547 1.410,1.696 <0.001 OR, odds ratio; CI, confidence interval. † Values in this table were performed by Early group as a reference. ‡ Adjusted for average age; gender; admission type; race; primary expected payer; admission day; location of hospital; teaching status of hospital; CCI; total comorbidities; Statistically significant preoperative comorbidities. A total of 29 Elixhauser comorbidities were readily available within the database from 2002 to 2014. The calculation of Charlson Comorbidity Index (CCI) is as shown in previous studies. 18 Data analysis The statistical software, SPSS version 26 (IBM Corp, Armonk, NY) was used to perform statistical analysis. All results were compared with the findings for the early group, which served as the benchmark for this study. We summarized the continuous variables by calculating their mean and standard deviation. Categorical variables were compared using chi-squared tests and continuous outcomes among 3 groups were compared using analysis of variance. We then performed multiple logistic and linear regression to compare the risk-adjusted associations of different surgical timing with in-hospital mortality and postoperative complications. The covariates considered in the multivariate regression included statistically significant demographics, hospital characteristics, and preoperative comorbidities. Statistical significance was defined using an alpha level of .001. Ethical approval Our study does not contain any studies with human participants or animals performed by any of the authors. As the database contains deidentified patient information, the study was deemed exempt by the institutional review board. Results Prevalences of intertrochanteric fractures and internal fixation A total of 369,116 geriatric patients with Ifs were treated surgically in the United States between 2002 and 2014, while 326,835 (88.521%) received an internal fixation. 228,725 people were eventually included in this study. The increasing trend of prevalence can be visualized in Figure 2. The prevalence of internal fixation was 85.374% in 2002, and it increased to 90.292% in 2014. Demographics Out of 228,725 patients who underwent internal fixation, 56,582 had procedures within 24 hours，148,910 within 1 to 2 days, and 23,233 within 3 to 7 days (Table 1). The shorter delays tended to be older, male, non-White, non-elective admission, weekend admission, had less hospitalization in rural areas and non-teaching hospitals, had more proportion of Medicare, more severe comorbidities (Table 1). The longer delays tended to be younger, male, non-White, non-elective admission, weekend admission, had less hospitalization in rural areas and non-teaching hospitals, had more proportion of Medicare, more severe comorbidities (Table 1). The distributions of pre-existing comorbidities conditions of all patients are shown in SUPPLEMENTARY TABLE 2. The majority of comorbidities showed significant differences in prevalence, except acquired immune deficiency syndrome, chronic blood loss anemia, drug abuse, lymphoma, neurological disorders, solid tumor without metastasis, and peptic ulcer disease. Total Cost, LOS, Postoperative length of hospital stay The average hospitalization costs were higher for patients who underwent procedures with shorter delays compared to those who underwent procedures early (Table 1). The longer delays had the highest hospitalization costs (67,894.898 ± 61840.851 USD), higher than that for patients undergoing procedures with shorter delays (46163.443 ± 37687.854 USD). Similar to our expectations, patients experienced longer hospital stays because they had longer delays for surgery. However, the shorter delays group had the least postoperative LOS (4.740 ± 3.624 days) compared with the other two groups (Early group: 4.906 ± 3.332 days; Longer delays group: 5.773 ± 5.557 days). Complications and Mortality Tables 2 and 3 detail the incidences and regression results of complications and mortality. In the unadjusted analysis (SUPPLEMENTARY TABLE 3), the shorter delays group showed higher ORs for cerebrovascular, cardiovascular, acute renal failure, pulmonary, venous thromboembolism, postoperative infection, and urinary complication. However, they showed lower ORs for systemic complication, and postoperative anemia. In addition, the longer delays group showed higher ORs for cerebrovascular, cardiovascular, acute renal failure, pulmonary, venous thromboembolism, mechanical wound, postoperative infection, and urinary complication. However, they showed lower ORs for systemic complication, and postoperative anemia. In the adjusted analysis (Table 3), the shorter delays group exhibited higher ORs for pulmonary, venous thromboembolism, postoperative infection, and urinary complication. The lower ORs were observed in postoperative anemia. There was no significant difference between shorter delays and the risk of mechanical wound and systemic complication. In addition, the longer delays group showed higher ORs for cerebrovascular, cardiovascular, acute renal failure, pulmonary, venous thromboembolism, postoperative infection, and urinary complication. The lower ORs were observed in postoperative anemia and systemic complication. The risk of other complications that did not show significant differences can be seen in Table 3. Mortality occurred in 1045 (1.847%) patients in early group, 3142 (2.110%) patients in shorter delays group, and 979 (4.214%) patients in longer delays group during internal fixation. Multivariable regression analysis suggested that longer delays (OR=1.547, 95%CI: 1.410-1.696, P<0.001) was associated with increased risk of in-hospital mortality in internal fixation procedures while no relationship was found in shorter delays (OR=1.024, 95%CI: 0.953-1.100, P= 0.520). Discussion We evaluated a large national cohort of more than 200,000 IF patients who underwent internal fixation procedures between 2002 and 2014 to determine the rate of in-hospital postoperative complications and mortality associated with different surgery timing. In this study, we discovered that delay surgery for elderly patients with IFs, compared with surgery performed early, is associated with developing adverse events. When the delay exceeds 48 hours, the risk of postoperative complications during hospitalization is greatly increased. Meanwhile, the association between delayed surgery and risk of in-patient mortality were enhanced. This emphasizes the importance of early surgery to improve clinical outcomes for these patients. Hip fractures include femoral neck fractures and IFs, and the preferred surgical methods for both are different. Internal fixation is widely regarded as the "gold standard" for treating IFs 4 ; 5 , but hip arthroplasty is more appropriate for elderly patients with femoral neck fractures. 17 Previous studies have reported early operative time and the prognosis of hip fractures. 14-16 ; 19 ; 20 Early surgery is appropriate for young, healthy patients 21-23 , while hip fractures primarily affect older patients with comorbidities, so there may have been selection bias in previous studies. In this study, we precisely defined age, fracture type, and surgical procedure. In addition, the larger sample size allowed us to unveil the intricate relationship between surgery timing and clinical outcomes. The guidelines recommend that surgery for IFs should be performed within 48 hours of admission, or even as short as the day or time of admission. 6 ; 7 In practice, the implementation of surgery is often affected by the philosophy, logistics and resources of the medical institution. In the UK health care system, out-of-hours surgery is approved in cases where there is a genuine threat to life or limb. 24 When investigating the causes of delayed surgery in hip fracture patients, Maria et al. discovered that more than half of patients with hip fractures lacked an operating room available for surgical treatment within 48 hours of admission. 16 In addition, a decrease in the number of experienced surgeons and supporting staff during off-hours admissions may affect impact the timely execution of surgery. 11 ; 25 Similarly, our study discovered a statistically significant difference in the proportion of patients experiencing delayed surgery on non-elective admission and weekend admission. Contrary to our initial suspicions, our analysis found that a higher proportion of patients had delayed surgery in urban or teaching hospitals. Elderly patients often have multiple comorbidities, which independently increase the risk of postoperative complications, and require multidisciplinary evaluation. 26-30 Optimizing the management of pre-existing medical conditions such as heart or lung issues by extending the waiting time for surgery can decrease the risk of complications or mortality following the procedure. 31 Anne et al. used the American Society of Anesthesiologists (ASA) score to evaluate patients' pre-surgery conditions and found that those with higher scores waited longer for surgery. 14 The CCI is widely regarded as the most reliable indicator for quantifying vulnerability. 32 ; 33 Rijckevorsel et al. used CCI to evaluate older patients with hip fractures before surgery and found no significant difference among the three groups. 34 Opposite, We discovered a statistically significant variance in CCI among the three groups, indicating that patients in the delayed group had a notably higher CCI. Interestingly, Using the comorbidity analysis provided in the database, we found that patients in the delayed group had more comorbidity. When we adjusted for these confounders, we found that the association between delayed surgery (especially longer delays) and poorer outcomes (higher risk of complications) persisted. The risk of pulmonary and venous thromboembolism associated with bed rest was significantly increased. Previous studies have shown conflicting effects of early surgery on mortality after hip fracture surgery. 35-37 Our study is the first to demonstrate the effect of prolonged waiting times for surgery on in-hospital mortality in patients with IFs. In-hospital mortality rates in our study were 2.110% and 4.214%, respectively, higher than those reported in previous studies, 38 ; 39 however, multiple logistic regression analysis showed that shorter delays was not associated with in-hospital death (OR: 1.024, CI: 0.953-1.088), longer delays was obviously associated with an increased risk of death during hospitalization (OR: 1.547, CI: 1.410-1.696). Moreover, Our study found that longer delays are associated with longer hospital stays and more hospital costs. Surgery delay directly increases the burden on individuals and the health care system. These findings suggest that early surgery is necessary. Unavoidably, our study had several limitations that attributable to the use of a large administrative database. First, the NIS database did not record the specific time of admission, so the impact of out-of-hours admission on postoperative outcomes could not be assessed. Secondly, there are difficult to obtain the details of surgical procedure, and these may influence ultimate complication rates. Also, the coding and documentation in the large database may be discrepancy or misclassification, which result in underestimating or overestimating the incidence of postoperative adverse events. 18 Finally, the negative effects of the time to surgery definition used in this study may be underrated or overestimated because the time of injury before surgery failed to be included in the NIS database. 34 Conclusion In conclusion, prolonged waiting time for surgery significantly increased the risk of postoperative complications, longer hospital stays and extra hospital charges, thereby increasing the burden on patients and the healthcare system. Moreover, our study showed that longer delays can amplify the risk of in-hospital mortality among older patients with IFs. Therefore, for individuals with clinical instability, reasonable preoperative optimization is necessary. For those without medical contraindications, early surgery appears to be the approach of choice. Declarations Acknowledgments Not applicable. Authors’ Contributions Z.J.P. performed data management and statistical analyses and drafted the original manuscript. Y.N.L. and H.T.D. participated in statistical analysis and revised the manuscript for intellectual content. W.J.F. performed literature reviews and revised the manuscript for intellectual content. Q.F.S. and K.Z. prepared figures and Tables. Y.Z. provided access to the data, conceived the research study and critically reviewed the manuscript. All authors read and approved the final manuscript. Data availability The datasets used and analysed during the current study available from the corresponding author (Y.Z.) on reasonable request. Competing interests The authors declare no conflict of interest. References Bhandari, M. & Swiontkowski, M. Management of Acute Hip Fracture. N Engl. J. Med. 377 , 2053–2062 (2017). Johnell, O. The Socioeconomic Burden of Fractures: Today and in the 21St Century. Am. J. Med. 103 , 25S–26S (1997). Li, R. Y. et al. Oral Versus Intravenous Tranexamic Acid in Elderly Patients with Intertrochanteric Fracture Undergoing Proximal Femur Intramedullary Nailing: A Prospective Cohort Study. J. Orthop. Translat . 34 , 85–90 (2022). Clayer, M. T. & Bauze, R. J. Morbidity and Mortality Following Fractures of the Femoral Neck and Trochanteric Region: Analysis of Risk Factors. J. Trauma. 29 , 1673–1678 (1989). Fröhlich, P. & Benkö, T. [DHS (Dynamic Hip Screw)-osteosynthesis in the Management of Femoral Fractures in the Hip Region and the Place of this Method in the Treatment of such Injuries]. Magy Traumatol. Ortop. Kezseb Plasztikai Seb . 36 , 59–64 (1993). NICE. The Management of Hip Fracture in Adults (National Clinical Guideline Centre, 2011). Roberts, K. C. & Brox, W. T. AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. J. Am. Acad. Orthop. Surg. 23 , 138–140 (2015). Beloosesky, Y. et al. Cytokines and C-reactive Protein Production in Hip-Fracture-Operated Elderly Patients. J. Gerontol. Biol. Sci. Med. Sci. 62 , 420–426 (2007). Chuang, D., Power, S. E., Dunbar, P. R. & Hill, A. G. Central Nervous System Interleukin-8 Production Following Neck of Femur Fracture. ANZ J. Surg. 75 , 813–816 (2005). Lans, A., Janssen, S. J. & Ring, D. Off-Hour Surgery Among Orthopedic Subspecialties at an Urban, Quaternary-Care, Level 1 Trauma Center. J. Hand Surg. Am. 41 , 1153–1158 (2016). Yeo, Q. Y. & Kwek, E. After Hours Surgery for Elderly Hip Fracture Patients: How Safe is It? Arch. Orthop. Trauma. Surg. 141 , 1183–1187 (2021). Sugden, C., Athanasiou, T. & Darzi, A. What are the Effects of Sleep Deprivation and Fatigue in Surgical Practice? Semin Thorac. Cardiovasc. Surg. 24 , 166–175 (2012). Hoogendijk, E. O. et al. Frailty: Implications for Clinical Practice and Public Health. Lancet . 394 , 1365–1375 (2019). Nyholm, A. M. et al. Time to Surgery is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators. J. Bone Joint Surg. Am. 97 , 1333–1339 (2015). Unnanuntana, A., Anusitviwat, C., Lertsiripatarajit, V., Riawraengsattha, P. & Raksakietisak, M. Early Hip Fracture Surgery within 24 Hours Did Not Reduce the Mortality Rate but Resulted in Less Postoperative Opioid Use and a Shorter Length of Stay: A Retrospective Study of 276 Patients From a Tertiary Private Hospital in Thailand. Geriatr. Orthop. Surg. Rehabil . 15 , 1751008922 (2024). Vidán, M. T. et al. Causes and Effects of Surgical Delay in Patients with Hip Fracture: A Cohort Study. Ann. Intern. Med. 155 , 226–233 (2011). Ju, D. G., Rajaee, S. S., Mirocha, J., Lin, C. A. & Moon, C. N. Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide. J. Bone Joint Surg. Am. 99 , 1932–1940 (2017). Yang, Q., Wang, J., Huang, X., Xu, Y. & Zhang, Y. Incidence and Risk Factors Associated with Postoperative Delirium Following Primary Elective Total Hip Arthroplasty: A Retrospective Nationwide Inpatient Sample Database Study. BMC Psychiatry . 20 , 343 (2020). Greve, K., Modig, K., Talbäck, M., Bartha, E. & Hedström, M. No Association Between Waiting Time to Surgery and Mortality for Healthier Patients with Hip Fracture: A Nationwide Swedish Cohort of 59,675 Patients. Acta Orthop. 91 , 396–400 (2020). Kelly-Pettersson, P. et al. Waiting Time to Surgery is Correlated with an Increased Risk of Serious Adverse Events During Hospital Stay in Patients with Hip-Fracture: A Cohort Study. Int. J. Nurs. Stud. 69 , 91–97 (2017). Bottle, A. & Aylin, P. Mortality Associated with Delay in Operation After Hip Fracture: Observational Study. BMJ . 332 , 947–951 (2006). Majumdar, S. R. et al. Lack of Association Between Mortality and Timing of Surgical Fixation in Elderly Patients with Hip Fracture: Results of a Retrospective Population-Based Cohort Study. Med. Care . 44 , 552–559 (2006). Moran, C. G., Wenn, R. T., Sikand, M. & Taylor, A. M. Early Mortality After Hip Fracture: Is Delay Before Surgery Important? J. Bone Joint Surg. Am. 87 , 483–489 (2005). Forssten, M. P. et al. The Consequences of Out-Of-Hours Hip Fracture Surgery: Insights From a Retrospective Nationwide Study. Eur. J. Trauma. Emerg. Surg. 48 , 709–719 (2022). Guo, J. et al. Is there a Weekend Effect in Intertrochanteric Fracture Surgery? Gerontology. 68 , 877–888 (2022). Holt, G., Smith, R., Duncan, K. & McKeown, D. W. Does Delay to Theatre for Medical Reasons Affect the Peri-Operative Mortality in Patients with a Fracture of the Hip? J. Bone Joint Surg. Br. 92 , 835–841 (2010). Lyons, A. R. Clinical Outcomes and Treatment of Hip Fractures. Am. J. Med. 103 , 63S–64S (1997). McLaughlin, M. A. et al. Preoperative Status and Risk of Complications in Patients with Hip Fracture. J. Gen. Intern. Med. 21 , 219–225 (2006). Söderqvist, A. et al. Prediction of Mortality in Elderly Patients with Hip Fractures: A Two-Year Prospective Study of 1,944 Patients. Gerontology . 55 , 496–504 (2009). Zuckerman, J. D. & Hip Fracture N Engl. J. Med. 334 , 1519–1525 (1996). Voeten, S. C., Baart, V. M., Krijnen, P. & Schipper, I. B. [Optimal Timing of a Hip Fracture Operation]. Ned Tijdschr Geneeskd 163 , (2019). Charlson, M. E., Pompei, P., Ales, K. L. & MacKenzie, C. R. A New Method of Classifying Prognostic Comorbidity in Longitudinal Studies: Development and Validation. J. Chronic Dis. 40 , 373–383 (1987). Karres, J., Heesakkers, N. A., Ultee, J. M. & Vrouenraets, B. C. Predicting 30-Day Mortality Following Hip Fracture Surgery: Evaluation of Six Risk Prediction Models. Injury . 46 , 371–377 (2015). van Rijckevorsel, V., de Jong, L., Verhofstad, M. & Roukema, G. R. Influence of Time to Surgery On Clinical Outcomes in Elderly Hip Fracture Patients: An Assessment of Surgical Postponement Due to Non-Medical Reasons. Bone Joint J. 104-B , 1369–1378 (2022). Moja, L. et al. Timing Matters in Hip Fracture Surgery: Patients Operated within 48 Hours Have Better Outcomes. A Meta-Analysis and Meta-Regression of Over 190,000 Patients. PLoS One . 7 , e46175 (2012). Shiga, T., Wajima, Z. & Ohe, Y. Is Operative Delay Associated with Increased Mortality of Hip Fracture Patients? Systematic Review, Meta-Analysis, and Meta-Regression. Can. J. Anaesth. 55 , 146–154 (2008). Simunovic, N. et al. Effect of Early Surgery After Hip Fracture On Mortality and Complications: Systematic Review and Meta-Analysis. CMAJ . 182 , 1609–1616 (2010). Lo, J. C. et al. Trends in Mortality Following Hip Fracture in Older Women. Am. J. Manag Care . 21 , e206–e214 (2015). Sasabuchi, Y., Matsui, H., Lefor, A. K., Fushimi, K. & Yasunaga, H. Timing of Surgery for Hip Fractures in the Elderly: A Retrospective Cohort Study. Injury . 49 , 1848–1854 (2018). Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5295283","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":383340297,"identity":"43fc418f-7ea5-4374-8f09-b4eca9459151","order_by":0,"name":"Zhijie Pan","email":"","orcid":"","institution":"The First People's Hospital of Zhaoqing","correspondingAuthor":false,"prefix":"","firstName":"Zhijie","middleName":"","lastName":"Pan","suffix":""},{"id":383340299,"identity":"8e074858-7ee5-494d-9e21-82d7c546ae04","order_by":1,"name":"Yuning Lin","email":"","orcid":"","institution":"The First People's Hospital of Zhaoqing","correspondingAuthor":false,"prefix":"","firstName":"Yuning","middleName":"","lastName":"Lin","suffix":""},{"id":383340300,"identity":"236300b2-1acd-44da-95c2-6839f51d81ee","order_by":2,"name":"Haitang Deng","email":"","orcid":"","institution":"The First People's Hospital of Zhaoqing","correspondingAuthor":false,"prefix":"","firstName":"Haitang","middleName":"","lastName":"Deng","suffix":""},{"id":383340301,"identity":"aa2a9511-6bfc-4302-9b77-a5e9b1f131b5","order_by":3,"name":"Wenjie Feng","email":"","orcid":"","institution":"The First People's Hospital of Zhaoqing","correspondingAuthor":false,"prefix":"","firstName":"Wenjie","middleName":"","lastName":"Feng","suffix":""},{"id":383340302,"identity":"44846001-c9c7-4a30-bc33-5ba523566f45","order_by":4,"name":"Qingfeng Shao","email":"","orcid":"","institution":"The First People's Hospital of Zhaoqing","correspondingAuthor":false,"prefix":"","firstName":"Qingfeng","middleName":"","lastName":"Shao","suffix":""},{"id":383340303,"identity":"b56e13c1-a9d5-48d2-b079-4f1d29f0d52e","order_by":5,"name":"Kai Zou","email":"","orcid":"","institution":"The First People's Hospital of Zhaoqing","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Zou","suffix":""},{"id":383340304,"identity":"f8229855-df7a-4833-b0a8-045b5b6bb95c","order_by":6,"name":"Yang Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYDAC5gMMBgwMNjz87A3EamFLAGlJk5HsOUCCFiA4bGNww4FIHeZs7BcKf7ad52G4wcD44WMOEVos23gKDCTbbvMwzm5glpy5jQgtBvd7EgwMgVqYZQ6wMfMSpeUYT4JBYts5HjaJBKK1sB8wONh2gIeHBC08DIYN55J5JHgONhPpl2Pszwx/lNnZ2x9vPvjhIzFaGBh4zAwY2UAMxgai1AMB++MHDH+IVTwKRsEoGAUjEgAA4XI1OicypmwAAAAASUVORK5CYII=","orcid":"","institution":"Nanfang Hospital, Southern Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yang","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-10-19 15:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5295283/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5295283/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71604569,"identity":"7ae9be97-c36f-4a22-a808-ed54ca6ced37","added_by":"auto","created_at":"2024-12-17 06:05:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94667,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the study participants selection process.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5295283/v1/37ce222d362529f557656c88.png"},{"id":71604570,"identity":"fbe02fdd-f14f-47c5-9283-50ffe9beeabf","added_by":"auto","created_at":"2024-12-17 06:06:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":86493,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of older patients undergoing internal fixation between 2002 and 2014.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5295283/v1/1fb7b3cf197b7b29a0c46c12.png"},{"id":72555064,"identity":"2069f8bd-5561-4b4b-bbd5-4089f0f3af3a","added_by":"auto","created_at":"2024-12-29 16:16:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":828182,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5295283/v1/a7e17893-09e1-43e4-9252-8aafe7a38388.pdf"},{"id":71604567,"identity":"669c5a84-e80a-4137-bc5c-d7c3aaddbf1c","added_by":"auto","created_at":"2024-12-17 06:05:59","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":22366,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5295283/v1/9f955ae6cbf05102ef9e5e63.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Effects of Surgical Delay in Older Patients with Intertrochanteric Fractures: Analysis from the National Inpatient Sample Database","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntertrochanteric fractures (IFs) were common in the older population. Worldwide, 4.5\u0026nbsp;million people are disabled from hip fracture each year, with projections indicating a potential increase to 6.3\u0026nbsp;million by 2050.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e; \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The IFs, one of the most prevalent types of hip fractures, accounts for approximately 50% of hip fractures\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e and exerts a significant financial burden on healthcare expenses and societal costs worldwide. Surgical treatment utilizing internal fixation, permitting immediate postoperative weight-bearing and reducing complications, is considered the \"gold standard technique\" for managing such fractures.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e; \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eGuidelines on hip fractures management across various countries recommend surgery within 48 hours or even as little as the same day or the time of admission.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e; \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Early surgery will reduce the time patients are exposed to those harmful states\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e; \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, which might increase the risk of medical complications and mortality. Numerous institutions schedule these procedures after hours to prompt the execution of such fracture surgeries.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e; \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, sleep deprivation and fatigue significantly compromise surgeons' neurocognitive abilities, heightening the potential for serious medical mishaps.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e On the other hand, Patients afflicted with numerous comorbidities frequently reside in a fragile condition, exhibiting clinical signs of diminished physiological resilience, heightened mortality risk, and enhanced sensitivity to stress.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Delaying surgery to optimize surgical planning and perioperative management based on the preoperative patient status is a viable approach for improving patient outcomes.\u003c/p\u003e \u003cp\u003eThe surgery timing for patients with IFs remains a topic of debate. Previous studies[26; 33; 35] on this subject were limited by factors such as small patient populations, which hindered a comprehensive understanding of patient demographics and early surgical outcomes. Therefore, we embarked on an investigation utilizing a database from the United States between 2002 and 2014 to depict the demographics of IFs patients with internal fixation and the surgical delay on clinical outcomes.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cp\u003eData were acquired from the National Inpatient Sample (NIS) database, a resource offered by the Healthcare Cost and Utilization Project (HCUP). The NIS stands as the largest all-payer database in the United States, containing discharge data garnered from a strategically selected 20% sample of community hospitals, comprehensively covering 95% of the US population. Each hospitalization record in the NIS database encompasses comprehensive data, spanning patient demographics, hospital characteristics, over 20 distinct diagnosis and procedure categories (defined by the International Classification of Diseases (ninth revision) Clinical Modification (ICD-9-CM)), accompanying comorbidities, length of stay, and the total associated charges.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eThe study population comprised hospitalizations in the United States from 2002 to 2014 for intertrochanteric fracture that received internal fixation treatment. We included all admissions with a diagnosis code for intertrochanteric fractures (ICD-9-CM codes of 820.21) and a procedure code for internal fixation (ICD-9-CM codes of 79.15, 79.35, 78.55).\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Patients with missing data, aged less than 60, and undergoing procedures over 7 days were excluded from this study.\u003c/p\u003e \u003cp\u003eSubsequently, we categorized the patients into 3 subgroups based on recommended surgical timing\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e; \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e after admission in the guidelines:1) early (within 24 hours), 2) shorter delay (1 to 2 days), and 3) longer delay (3 to 7 days). The detailed flow can be visualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eStudy Variable\u003c/h3\u003e\n\u003cp\u003ePatient demographics and hospital characteristics were evaluated. Outcome measures such as length of stay (LOS), total hospitalization costs, in-hospital mortality, and postoperative complications were analyzed. We searched the database for postoperative complications before discharge, utilizing the ICD-9-CM diagnostic code. We determined cerebrovascular, cardiovascular, acute renal failure, pulmonary including respiratory failure and pneumonia, venous thromboembolism including deep vein thrombosis and pulmonary embolism, mechanical wound included surgical wound dehiscence and hematoma, systemic complication included septic shock and hemorrhage, post-operative infection, urinary complication, as well as post-operative anemia as in-hospital postoperative complications in IF patients. The specific ICD-9 codes for complications are listed below SUPPLEMENTARY TABLE \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of Older Patients Undergoing Internal Fixation For intertrochanteric fractures During Different Surgery Timing.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;56582)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShorter Delay\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;148910)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLonger Delay\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;23233)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage age (y) (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.099\u0026thinsp;\u0026plusmn;\u0026thinsp;8.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.420\u0026thinsp;\u0026plusmn;\u0026thinsp;8.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.018\u0026thinsp;\u0026plusmn;\u0026thinsp;8.330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.914\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission type (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-elective admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.822\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRACE (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.518\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.722\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.435\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.462\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian or Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.410\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.756\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNative American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary expected payer (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.924\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.739\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.748\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo charge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission day (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonday-Friday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaturday-Sunday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of hospital (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.740\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.792\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.855\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching status of hospital (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonteaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.883\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.451\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.549\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.140\u0026thinsp;\u0026plusmn;\u0026thinsp;1.458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.277\u0026thinsp;\u0026plusmn;\u0026thinsp;1.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.685\u0026thinsp;\u0026plusmn;\u0026thinsp;1.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal comorbidities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.857\u0026thinsp;\u0026plusmn;\u0026thinsp;1.738\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.107\u0026thinsp;\u0026plusmn;\u0026thinsp;1.779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.686\u0026thinsp;\u0026plusmn;\u0026thinsp;1.923\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.847\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003elength of stay (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.906\u0026thinsp;\u0026plusmn;\u0026thinsp;3.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.997\u0026thinsp;\u0026plusmn;\u0026thinsp;3.669\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.594\u0026thinsp;\u0026plusmn;\u0026thinsp;5.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative LOS (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.906\u0026thinsp;\u0026plusmn;\u0026thinsp;3.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.740\u0026thinsp;\u0026plusmn;\u0026thinsp;3.624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.773\u0026thinsp;\u0026plusmn;\u0026thinsp;5.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hospitalization costs (USD) (\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40162.789\u0026thinsp;\u0026plusmn;\u0026thinsp;33646.526\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46163.443\u0026thinsp;\u0026plusmn;\u0026thinsp;37687.854\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67894.898\u0026thinsp;\u0026plusmn;\u0026thinsp;61840.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eCCI: Charlson Comorbidity Index; SD: standard deviation; USD: US dollar\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIncidence of Complications in Older Patients Undergoing internal fixation For Intertrochanteric Fractures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEarly\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShorter Delay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLonger Delay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.719\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.541\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.490\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.755%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute renal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous thromboembolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.746\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.484\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical wound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary complication,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative anemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.377\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate Regression Results of Postoperative Complications and Mortality. \u0026dagger;\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eShorter Delay\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eLonger Delay\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR \u0026Dagger;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR \u0026Dagger;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.975\u0026ndash;1.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.642\u0026ndash;2.248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.995\u0026ndash;1.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.771\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.637\u0026ndash;1.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute renal failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.990\u0026ndash;1.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.410\u0026ndash;1.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.056\u0026ndash;1.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.928\u0026ndash;2.147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVenous thromboembolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.318\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.181\u0026ndash;1.471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.178\u0026ndash;2.844\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical wound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.759\u0026ndash;0.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.951\u0026ndash;1.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.821\u0026ndash;0.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.708\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.602\u0026ndash;0.832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.100-1.725\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.489\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.900\u0026ndash;3.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.203\u0026ndash;1.269\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.791\u0026ndash;1.934\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-operative anemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.863\u0026ndash;0.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.494\u0026ndash;0.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.953,1.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.410,1.696\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eOR, odds ratio; CI, confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026dagger; Values in this table were performed by Early group as a reference.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u0026Dagger; Adjusted for average age; gender; admission type; race; primary expected payer; admission day; location of hospital; teaching status of hospital; CCI; total comorbidities; Statistically significant preoperative comorbidities.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 29 Elixhauser comorbidities were readily available within the database from 2002 to 2014. The calculation of Charlson Comorbidity Index (CCI) is as shown in previous studies.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe statistical software, SPSS version 26 (IBM Corp, Armonk, NY) was used to perform statistical analysis. All results were compared with the findings for the early group, which served as the benchmark for this study. We summarized the continuous variables by calculating their mean and standard deviation. Categorical variables were compared using chi-squared tests and continuous outcomes among 3 groups were compared using analysis of variance. We then performed multiple logistic and linear regression to compare the risk-adjusted associations of different surgical timing with in-hospital mortality and postoperative complications. The covariates considered in the multivariate regression included statistically significant demographics, hospital characteristics, and preoperative comorbidities. Statistical significance was defined using an alpha level of .001.\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eOur study does not contain any studies with human participants or animals performed by any of the authors. As the database contains deidentified patient information, the study was deemed exempt by the institutional review board.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePrevalences of intertrochanteric fractures and internal fixation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 369,116\u0026nbsp;geriatric patients with Ifs were treated surgically in the United States between 2002 and 2014, while 326,835 (88.521%) received an internal fixation. 228,725 people were eventually included in this study. The increasing trend of prevalence can be visualized in Figure 2. The prevalence of internal fixation was 85.374% in 2002, and it increased to 90.292% in 2014.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 228,725 patients who underwent internal fixation, 56,582 had procedures within 24 hours，148,910 within 1 to 2 days, and 23,233\u0026nbsp;within 3 to 7 days (Table 1). The shorter delays tended to be older, male, non-White, non-elective admission, weekend admission, had less hospitalization in rural areas and non-teaching hospitals, had more proportion of Medicare, more severe comorbidities (Table 1).\u0026nbsp;The longer delays tended to be younger, male, non-White, non-elective admission, weekend admission, had less hospitalization in rural areas and non-teaching hospitals, had more proportion of Medicare, more severe comorbidities (Table 1). The distributions of pre-existing comorbidities\u0026nbsp;conditions of all patients are shown in SUPPLEMENTARY TABLE 2. The majority of comorbidities showed significant differences in prevalence, except acquired immune deficiency syndrome, chronic blood loss anemia, drug abuse, lymphoma, neurological disorders, solid tumor without metastasis, and peptic ulcer disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTotal Cost, LOS, Postoperative length of hospital stay\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe average hospitalization costs were higher for patients who underwent procedures with shorter delays\u0026nbsp;compared to those who underwent procedures early (Table 1). The longer delays had the highest hospitalization costs (67,894.898 \u0026plusmn; 61840.851 USD), higher than that for patients undergoing procedures with shorter delays (46163.443 \u0026plusmn; 37687.854 USD).\u003c/p\u003e\n\u003cp\u003eSimilar to our expectations, patients experienced longer hospital stays because they had longer delays for surgery. However, the shorter delays group had the least postoperative LOS (4.740 \u0026plusmn; 3.624 days) compared with the other two groups (Early group: 4.906 \u0026plusmn; 3.332 days; Longer delays group: 5.773 \u0026plusmn; 5.557 days).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications and Mortality\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTables 2 and 3 detail the incidences and regression results of complications and mortality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the unadjusted analysis (SUPPLEMENTARY TABLE 3), the shorter delays group showed higher ORs for cerebrovascular, cardiovascular, acute renal failure, pulmonary, venous thromboembolism, postoperative infection, and urinary complication. However, they showed lower ORs for systemic complication, and postoperative anemia. In addition, the longer delays group showed higher ORs for cerebrovascular, cardiovascular, acute renal failure, pulmonary, venous thromboembolism, mechanical wound, postoperative infection, and urinary complication. However, they showed lower ORs for systemic complication, and postoperative anemia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the adjusted analysis (Table 3), the shorter delays\u0026nbsp;group exhibited higher ORs for pulmonary, venous thromboembolism, postoperative infection, and urinary complication. The lower ORs were observed in postoperative anemia. There was no significant difference between shorter delays and the risk of mechanical wound and systemic complication. In addition, the longer delays group showed higher ORs for cerebrovascular, cardiovascular, acute renal failure, pulmonary, venous thromboembolism, postoperative infection, and urinary complication. The lower ORs were observed in postoperative anemia and systemic complication. The risk of other complications that did not show significant differences can be seen in Table 3.\u003c/p\u003e\n\u003cp\u003eMortality occurred in 1045 (1.847%) patients in early group, 3142 (2.110%) patients in shorter delays group, and 979 (4.214%) patients in longer delays group during internal fixation. Multivariable regression analysis suggested that longer delays (OR=1.547, 95%CI: 1.410-1.696, P\u0026lt;0.001) was associated with increased risk of in-hospital mortality in internal fixation procedures while no relationship was found in shorter delays (OR=1.024, 95%CI: 0.953-1.100, P= 0.520).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe evaluated a large national cohort of more than 200,000 IF patients who underwent internal fixation\u0026nbsp;procedures between 2002 and 2014 to determine the rate of in-hospital postoperative complications and mortality associated with different surgery timing. In this study, we discovered that delay surgery for elderly patients with IFs, compared with surgery performed early, is associated with developing adverse events. When the delay exceeds 48 hours, the risk of postoperative complications during hospitalization is greatly increased. Meanwhile, the association between delayed surgery and risk of in-patient mortality were enhanced. This emphasizes the importance of early surgery to improve clinical outcomes for these patients.\u003c/p\u003e\n\u003cp\u003eHip fractures include femoral neck fractures and IFs, and the preferred surgical methods for both are different. Internal fixation is widely regarded as the \u0026quot;gold standard\u0026quot; for treating IFs\u003csup\u003e4\u003c/sup\u003e; \u003csup\u003e5\u003c/sup\u003e, but hip arthroplasty is more appropriate for elderly patients with femoral neck fractures.\u003csup\u003e17\u003c/sup\u003e Previous studies have reported early operative time and the prognosis of hip fractures.\u003csup\u003e14-16\u003c/sup\u003e; \u003csup\u003e19\u003c/sup\u003e; \u003csup\u003e20\u003c/sup\u003e Early surgery is appropriate for young, healthy patients\u003csup\u003e21-23\u003c/sup\u003e, while hip fractures primarily affect older patients with comorbidities, so there may have been selection bias in previous studies. In this study, we precisely defined age, fracture type, and surgical procedure. In addition, the larger sample size allowed us to unveil the intricate relationship between surgery timing and clinical outcomes.\u003c/p\u003e\n\u003cp\u003eThe guidelines recommend that surgery for IFs should be performed within 48 hours of admission, or even as short as the day or time of admission.\u003csup\u003e6\u003c/sup\u003e; \u003csup\u003e7\u003c/sup\u003e In practice, the implementation of surgery is often affected by the philosophy, logistics and resources of the medical institution. In the UK health care system, out-of-hours surgery is approved in cases where there is a genuine threat to life or limb.\u003csup\u003e24\u003c/sup\u003e When investigating the causes of delayed surgery in hip fracture patients, Maria et al. discovered that more than half of patients with hip fractures lacked an operating room available for surgical treatment within 48 hours of admission.\u003csup\u003e16\u003c/sup\u003e In addition, a decrease in the number of experienced surgeons and supporting staff during off-hours admissions may affect impact the timely execution of surgery.\u003csup\u003e11\u003c/sup\u003e; \u003csup\u003e25\u003c/sup\u003e Similarly, our study discovered a statistically significant difference in the proportion of patients experiencing delayed surgery on non-elective admission and weekend admission. Contrary to our initial suspicions, our analysis found that a higher proportion of patients had delayed surgery in urban or teaching hospitals.\u003c/p\u003e\n\u003cp\u003eElderly patients often have multiple comorbidities, which independently increase the risk of postoperative complications, and require multidisciplinary evaluation.\u003csup\u003e26-30\u003c/sup\u003e Optimizing the management of pre-existing medical conditions such as heart or lung issues by extending the waiting time for surgery can decrease the risk of complications or mortality following the procedure.\u003csup\u003e31\u003c/sup\u003e Anne et al. used the American Society of Anesthesiologists (ASA) score to evaluate patients\u0026apos; pre-surgery conditions and found that those with higher scores waited longer for surgery.\u003csup\u003e14\u003c/sup\u003e The CCI is widely regarded as the most reliable indicator for quantifying vulnerability.\u003csup\u003e32\u003c/sup\u003e; \u003csup\u003e33\u003c/sup\u003e Rijckevorsel et al. used CCI to evaluate older patients with hip fractures before surgery and found no significant difference among the three groups.\u003csup\u003e34\u003c/sup\u003e Opposite, We discovered a statistically significant variance in CCI among the three groups, indicating that patients in the delayed group had a notably higher CCI. Interestingly, Using the comorbidity analysis provided in the database, we found that patients in the delayed group had more comorbidity. When we adjusted for these confounders, we found that the association between delayed surgery (especially longer delays) and poorer outcomes (higher risk of complications) persisted. The risk of pulmonary and venous thromboembolism associated with bed rest was significantly increased.\u003c/p\u003e\n\u003cp\u003ePrevious studies have shown conflicting effects of early surgery on mortality after hip fracture surgery.\u003csup\u003e35-37\u003c/sup\u003e Our study is the first to demonstrate the effect of prolonged waiting times for surgery on in-hospital mortality in patients with IFs. In-hospital mortality rates in our study were 2.110% and\u0026nbsp;4.214%, respectively, higher than those reported in previous studies,\u003csup\u003e38\u003c/sup\u003e; \u003csup\u003e39\u003c/sup\u003e however, multiple logistic regression analysis showed that shorter delays was not associated with in-hospital death (OR: 1.024, CI: 0.953-1.088), longer delays was obviously associated with an increased risk of death during hospitalization (OR: 1.547, CI: 1.410-1.696). Moreover, Our study found that longer delays are associated with longer hospital stays and more hospital costs. Surgery delay directly increases the burden on individuals and the health care system. These findings suggest that early surgery is necessary.\u003c/p\u003e\n\u003cp\u003eUnavoidably, our study had several limitations that attributable to the use of a large administrative database. First, the NIS database did not record the specific time of admission, so the impact of out-of-hours admission on postoperative outcomes could not be assessed. Secondly, there are difficult to obtain the details of surgical procedure, and these may influence ultimate complication rates. Also, the coding and documentation in the large database may be discrepancy or misclassification, which result in underestimating or overestimating the incidence of postoperative adverse events.\u003csup\u003e18\u003c/sup\u003e Finally, the negative effects of the time to surgery definition used in this study may be underrated or overestimated because the time of injury before surgery failed to be included in the NIS database.\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, prolonged waiting time for surgery significantly increased the risk of postoperative complications, longer hospital stays and extra hospital charges, thereby increasing the burden on patients and the healthcare system. Moreover, our study showed that longer delays can amplify the risk of in-hospital mortality among older patients with IFs. Therefore, for individuals with clinical instability, reasonable preoperative optimization is necessary. For those without medical contraindications, early surgery appears to be the approach of choice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZ.J.P. performed data management and statistical analyses and drafted the original manuscript. Y.N.L. and H.T.D. participated in statistical analysis and revised the manuscript for intellectual content. W.J.F. performed literature reviews and revised the manuscript for intellectual content. Q.F.S. and K.Z. prepared figures and Tables. Y.Z. provided access to the data, conceived the research study and critically reviewed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study available from the corresponding author (Y.Z.) on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBhandari, M. \u0026amp; Swiontkowski, M. Management of Acute Hip Fracture. \u003cem\u003eN Engl. J. Med.\u003c/em\u003e \u003cb\u003e377\u003c/b\u003e, 2053\u0026ndash;2062 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnell, O. The Socioeconomic Burden of Fractures: Today and in the 21St Century. \u003cem\u003eAm. J. Med.\u003c/em\u003e \u003cb\u003e103\u003c/b\u003e, 25S\u0026ndash;26S (1997).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi, R. Y. et al. Oral Versus Intravenous Tranexamic Acid in Elderly Patients with Intertrochanteric Fracture Undergoing Proximal Femur Intramedullary Nailing: A Prospective Cohort Study. \u003cem\u003eJ. Orthop. Translat\u003c/em\u003e. \u003cb\u003e34\u003c/b\u003e, 85\u0026ndash;90 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClayer, M. T. \u0026amp; Bauze, R. J. Morbidity and Mortality Following Fractures of the Femoral Neck and Trochanteric Region: Analysis of Risk Factors. \u003cem\u003eJ. Trauma.\u003c/em\u003e \u003cb\u003e29\u003c/b\u003e, 1673\u0026ndash;1678 (1989).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFr\u0026ouml;hlich, P. \u0026amp; Benk\u0026ouml;, T. [DHS (Dynamic Hip Screw)-osteosynthesis in the Management of Femoral Fractures in the Hip Region and the Place of this Method in the Treatment of such Injuries]. \u003cem\u003eMagy Traumatol. Ortop. Kezseb Plasztikai Seb\u003c/em\u003e. \u003cb\u003e36\u003c/b\u003e, 59\u0026ndash;64 (1993).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE. \u003cem\u003eThe Management of Hip Fracture in Adults\u003c/em\u003e (National Clinical Guideline Centre, 2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts, K. C. \u0026amp; Brox, W. T. AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. \u003cem\u003eJ. Am. Acad. Orthop. Surg.\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e, 138\u0026ndash;140 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeloosesky, Y. et al. Cytokines and C-reactive Protein Production in Hip-Fracture-Operated Elderly Patients. \u003cem\u003eJ. Gerontol. Biol. Sci. Med. Sci.\u003c/em\u003e \u003cb\u003e62\u003c/b\u003e, 420\u0026ndash;426 (2007).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChuang, D., Power, S. E., Dunbar, P. R. \u0026amp; Hill, A. G. Central Nervous System Interleukin-8 Production Following Neck of Femur Fracture. \u003cem\u003eANZ J. Surg.\u003c/em\u003e \u003cb\u003e75\u003c/b\u003e, 813\u0026ndash;816 (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLans, A., Janssen, S. J. \u0026amp; Ring, D. Off-Hour Surgery Among Orthopedic Subspecialties at an Urban, Quaternary-Care, Level 1 Trauma Center. \u003cem\u003eJ. Hand Surg. Am.\u003c/em\u003e \u003cb\u003e41\u003c/b\u003e, 1153\u0026ndash;1158 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYeo, Q. Y. \u0026amp; Kwek, E. After Hours Surgery for Elderly Hip Fracture Patients: How Safe is It? \u003cem\u003eArch. Orthop. Trauma. Surg.\u003c/em\u003e \u003cb\u003e141\u003c/b\u003e, 1183\u0026ndash;1187 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugden, C., Athanasiou, T. \u0026amp; Darzi, A. What are the Effects of Sleep Deprivation and Fatigue in Surgical Practice? \u003cem\u003eSemin Thorac. Cardiovasc. Surg.\u003c/em\u003e \u003cb\u003e24\u003c/b\u003e, 166\u0026ndash;175 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoogendijk, E. O. et al. Frailty: Implications for Clinical Practice and Public Health. \u003cem\u003eLancet\u003c/em\u003e. \u003cb\u003e394\u003c/b\u003e, 1365\u0026ndash;1375 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyholm, A. M. et al. Time to Surgery is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators. \u003cem\u003eJ. Bone Joint Surg. Am.\u003c/em\u003e \u003cb\u003e97\u003c/b\u003e, 1333\u0026ndash;1339 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnnanuntana, A., Anusitviwat, C., Lertsiripatarajit, V., Riawraengsattha, P. \u0026amp; Raksakietisak, M. Early Hip Fracture Surgery within 24 Hours Did Not Reduce the Mortality Rate but Resulted in Less Postoperative Opioid Use and a Shorter Length of Stay: A Retrospective Study of 276 Patients From a Tertiary Private Hospital in Thailand. \u003cem\u003eGeriatr. Orthop. Surg. Rehabil\u003c/em\u003e. \u003cb\u003e15\u003c/b\u003e, 1751008922 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVid\u0026aacute;n, M. T. et al. Causes and Effects of Surgical Delay in Patients with Hip Fracture: A Cohort Study. \u003cem\u003eAnn. Intern. Med.\u003c/em\u003e \u003cb\u003e155\u003c/b\u003e, 226\u0026ndash;233 (2011).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJu, D. G., Rajaee, S. S., Mirocha, J., Lin, C. A. \u0026amp; Moon, C. N. Nationwide Analysis of Femoral Neck Fractures in Elderly Patients: A Receding Tide. \u003cem\u003eJ. Bone Joint Surg. Am.\u003c/em\u003e \u003cb\u003e99\u003c/b\u003e, 1932\u0026ndash;1940 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang, Q., Wang, J., Huang, X., Xu, Y. \u0026amp; Zhang, Y. Incidence and Risk Factors Associated with Postoperative Delirium Following Primary Elective Total Hip Arthroplasty: A Retrospective Nationwide Inpatient Sample Database Study. \u003cem\u003eBMC Psychiatry\u003c/em\u003e. \u003cb\u003e20\u003c/b\u003e, 343 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreve, K., Modig, K., Talb\u0026auml;ck, M., Bartha, E. \u0026amp; Hedstr\u0026ouml;m, M. No Association Between Waiting Time to Surgery and Mortality for Healthier Patients with Hip Fracture: A Nationwide Swedish Cohort of 59,675 Patients. \u003cem\u003eActa Orthop.\u003c/em\u003e \u003cb\u003e91\u003c/b\u003e, 396\u0026ndash;400 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly-Pettersson, P. et al. Waiting Time to Surgery is Correlated with an Increased Risk of Serious Adverse Events During Hospital Stay in Patients with Hip-Fracture: A Cohort Study. \u003cem\u003eInt. J. Nurs. Stud.\u003c/em\u003e \u003cb\u003e69\u003c/b\u003e, 91\u0026ndash;97 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBottle, A. \u0026amp; Aylin, P. Mortality Associated with Delay in Operation After Hip Fracture: Observational Study. \u003cem\u003eBMJ\u003c/em\u003e. \u003cb\u003e332\u003c/b\u003e, 947\u0026ndash;951 (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajumdar, S. R. et al. Lack of Association Between Mortality and Timing of Surgical Fixation in Elderly Patients with Hip Fracture: Results of a Retrospective Population-Based Cohort Study. \u003cem\u003eMed. Care\u003c/em\u003e. \u003cb\u003e44\u003c/b\u003e, 552\u0026ndash;559 (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoran, C. G., Wenn, R. T., Sikand, M. \u0026amp; Taylor, A. M. Early Mortality After Hip Fracture: Is Delay Before Surgery Important? J. \u003cem\u003eBone Joint Surg. Am.\u003c/em\u003e \u003cb\u003e87\u003c/b\u003e, 483\u0026ndash;489 (2005).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForssten, M. P. et al. The Consequences of Out-Of-Hours Hip Fracture Surgery: Insights From a Retrospective Nationwide Study. \u003cem\u003eEur. J. Trauma. Emerg. Surg.\u003c/em\u003e \u003cb\u003e48\u003c/b\u003e, 709\u0026ndash;719 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo, J. et al. Is there a Weekend Effect in Intertrochanteric Fracture Surgery? Gerontology. \u003cb\u003e68\u003c/b\u003e, 877\u0026ndash;888 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolt, G., Smith, R., Duncan, K. \u0026amp; McKeown, D. W. Does Delay to Theatre for Medical Reasons Affect the Peri-Operative Mortality in Patients with a Fracture of the Hip? \u003cem\u003eJ. Bone Joint Surg. Br.\u003c/em\u003e \u003cb\u003e92\u003c/b\u003e, 835\u0026ndash;841 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyons, A. R. Clinical Outcomes and Treatment of Hip Fractures. \u003cem\u003eAm. J. Med.\u003c/em\u003e \u003cb\u003e103\u003c/b\u003e, 63S\u0026ndash;64S (1997).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLaughlin, M. A. et al. Preoperative Status and Risk of Complications in Patients with Hip Fracture. \u003cem\u003eJ. Gen. Intern. Med.\u003c/em\u003e \u003cb\u003e21\u003c/b\u003e, 219\u0026ndash;225 (2006).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026ouml;derqvist, A. et al. Prediction of Mortality in Elderly Patients with Hip Fractures: A Two-Year Prospective Study of 1,944 Patients. \u003cem\u003eGerontology\u003c/em\u003e. \u003cb\u003e55\u003c/b\u003e, 496\u0026ndash;504 (2009).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZuckerman, J. D. \u0026amp; Hip Fracture \u003cem\u003eN Engl. J. Med.\u003c/em\u003e \u003cb\u003e334\u003c/b\u003e, 1519\u0026ndash;1525 (1996).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoeten, S. C., Baart, V. M., Krijnen, P. \u0026amp; Schipper, I. B. [Optimal Timing of a Hip Fracture Operation]. \u003cem\u003eNed Tijdschr Geneeskd\u003c/em\u003e \u003cb\u003e163\u003c/b\u003e, (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharlson, M. E., Pompei, P., Ales, K. L. \u0026amp; MacKenzie, C. R. A New Method of Classifying Prognostic Comorbidity in Longitudinal Studies: Development and Validation. \u003cem\u003eJ. Chronic Dis.\u003c/em\u003e \u003cb\u003e40\u003c/b\u003e, 373\u0026ndash;383 (1987).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarres, J., Heesakkers, N. A., Ultee, J. M. \u0026amp; Vrouenraets, B. C. Predicting 30-Day Mortality Following Hip Fracture Surgery: Evaluation of Six Risk Prediction Models. \u003cem\u003eInjury\u003c/em\u003e. \u003cb\u003e46\u003c/b\u003e, 371\u0026ndash;377 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Rijckevorsel, V., de Jong, L., Verhofstad, M. \u0026amp; Roukema, G. R. Influence of Time to Surgery On Clinical Outcomes in Elderly Hip Fracture Patients: An Assessment of Surgical Postponement Due to Non-Medical Reasons. \u003cem\u003eBone Joint J.\u003c/em\u003e \u003cb\u003e104-B\u003c/b\u003e, 1369\u0026ndash;1378 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoja, L. et al. Timing Matters in Hip Fracture Surgery: Patients Operated within 48 Hours Have Better Outcomes. A Meta-Analysis and Meta-Regression of Over 190,000 Patients. \u003cem\u003ePLoS One\u003c/em\u003e. \u003cb\u003e7\u003c/b\u003e, e46175 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiga, T., Wajima, Z. \u0026amp; Ohe, Y. Is Operative Delay Associated with Increased Mortality of Hip Fracture Patients? Systematic Review, Meta-Analysis, and Meta-Regression. \u003cem\u003eCan. J. Anaesth.\u003c/em\u003e \u003cb\u003e55\u003c/b\u003e, 146\u0026ndash;154 (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimunovic, N. et al. Effect of Early Surgery After Hip Fracture On Mortality and Complications: Systematic Review and Meta-Analysis. \u003cem\u003eCMAJ\u003c/em\u003e. \u003cb\u003e182\u003c/b\u003e, 1609\u0026ndash;1616 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLo, J. C. et al. Trends in Mortality Following Hip Fracture in Older Women. \u003cem\u003eAm. J. Manag Care\u003c/em\u003e. \u003cb\u003e21\u003c/b\u003e, e206\u0026ndash;e214 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSasabuchi, Y., Matsui, H., Lefor, A. K., Fushimi, K. \u0026amp; Yasunaga, H. Timing of Surgery for Hip Fractures in the Elderly: A Retrospective Cohort Study. \u003cem\u003eInjury\u003c/em\u003e. \u003cb\u003e49\u003c/b\u003e, 1848\u0026ndash;1854 (2018).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5295283/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5295283/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe clinical effect of surgery timing in older patients with intertrochanteric fractures (IFs) is controversial. Our objective was to assess the association between surgery timing and in-hospital mortality and postoperative complications in these patients. In our study, 228,725 patients accepted internal fixation surgery for IFs were obtained from the 2002 to 2014 Nationwide inpatient sample (NIS) database. They were categorized into 3 subgroups according to the time of admission to surgery: early, shorter delays, and longer delays. The prevalence of internal fixation surgery in IFs patients significantly increased over time. Delays in surgery were associated with longer LOS, extra hospital charges, and higher risk of postoperative complications. Rates of in-hospital death were 2.110% and 4.214%, respectively in two delay groups. After adjustment, shorter delays was not associated with in-hospital death (OR: 1.024, CI: 0.953, 1.088;P\u0026thinsp;=\u0026thinsp;0.520), longer delays was obviously associated with an increased risk of death during hospitalization (OR: 1.547, CI: 1.410, 1.696;P\u0026lt;0.001). Prolonged waiting time for surgery significantly increased the risk of developing adverse events. Therefore, reasonable preoperative optimization and strive for early surgery are necessary.\u003c/p\u003e","manuscriptTitle":"Clinical Effects of Surgical Delay in Older Patients with Intertrochanteric Fractures: Analysis from the National Inpatient Sample Database","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 06:05:54","doi":"10.21203/rs.3.rs-5295283/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d43c07da-5594-438d-80d3-8f83eebb79e4","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":40831659,"name":"Health sciences/Medical research/Outcomes research"},{"id":40831660,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-03-13T02:53:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-17 06:05:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5295283","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5295283","identity":"rs-5295283","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}