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Hip Fracture and the Weekend Effect: Does Weekend Admission Affect Patient Outcomes?

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Hip Fracture and the Weekend Effect: Does Weekend Admission Affect Patient Outcomes? An Original Study Hip Fracture and the Weekend Effect: Does Weekend Admission Affect Patient Outcomes? Matthew R. Boylan, ScB, Janet Rosenbaum, PhD, Adam Adler, MD, Qais Naziri, MD, and Carl B. Paulino, MD management for patients admitted for traumatic and emergent Abstract conditions. Investigators have found increased mortality in Reduced hospital staffing on weekends is a hypoth- weekend admissions for stroke,2 subdural hematoma,3 gas- esized risk factor for adverse health outcomes—com- trointestinal bleeding,4,5 atrial fibrillation,6 and pulmonary monly referred to as the weekend effect. embolism.7 Investigators have not found increased mortality We conducted a study on the effect of weekend in weekend admissions for hip fracture, though the majority admission on short-term outcomes among US hip of the data was derived from European patient populations, fracture patients. We selected Nationwide Inpatient which may be subject to management and staffing strategies Sample (1998–2010) patients with a principal diagnosis different from those for US patients.8-10 Furthermore, data on of femoral neck fracture and grouped them by day of this topic in US patients are limited to a multispecialty study admission (weekend or weekday). We used multivariate of 50 different admission diagnoses, which used 1 year of data logistic and linear regression analyses, controlling for from a single US state.1 age, race, sex, number of comorbidities, and other risk We conducted a study to comprehensively assess the effect factors, to calculate odds ratios (ORs) of mAJOortality and of weekend admission on adverse outcomes during hospital perioperative complications as well as mean difference stays. The literature suggests that surgery for hip fracture can in length of hospital stay. be delayed up to 48 hours without significant additional risk of Our study population included 96,892 weekend and death,11-13 allowing orthopedic departments to stabilize routine 248,097 weekday admissions. Compared with patients hip fracture admissions on weekends and operate whenever admitted on weekdays, patients admitted on week- limited surgical teams become available. Surgical delay has ends had lower mortality (OR, 0.94; 95% confidence not been thoroughly analyzed by day of admission among US 14 DOinterval [CI], 0.89-0.99) a nd shorterNOT mean hospital stay patients, COPYbut the combined potential of more conservative (estimate, 3.74%; 95% CI, 3.40-4.08) but did not differ preoperative management and the availability of fewer senior in risk of perioperative complications (OR, 1.00; 95% physicians and ancillary providers may result in worse out- CI, 0.98-1.02). comes for weekend versus weekday admissions. Weekend admission did not predict death, periop- erative complications, longer hospital stay, or other Materials and Methods adverse short-term outcomes. Our study data do not support a weekend effect among hip fracture admis- Study Population sions in the United States. Part of the Healthcare Cost and Utilization Project, the Nation- wide Inpatient Sample (NIS) provides a 20% representative sample of annual US hospital admissions.15 For these admis- sions, the NIS includes data related to demographic and clinical eekend admission has been hypothesized to be variables, such as International Classification of Diseases, Ninth Revision, a risk factor for increased patient mortality and Clinical Modification (ICD-9-CM) diagnosis and procedure codes, as Wcomplications during hospital stays—commonly well as descriptive variables for the hospitals where the patients referred to as the weekend effect.1 Reduced hospital staffing on were admitted. The NIS is publicly available to researchers. As weekends, particularly of senior-level physicians and ancil- its health information is deidentified, we did not have to obtain lary nursing services, may affect the quality of diagnosis and institutional review board approval for this study. Authors’ Disclosure Statement: Dr. Paulino had a prior relationship with Ethicon for lecture services unrelated to this project. Dr. Rosenbaum is a consultant to the Health Resources and Services Administration and the California Healthy Kids program. She has received grants from the Spencer Foundation, the National Institute on Drug Abuse, the American Educational Research Association, the American Institutes for Research, and the National Institutes of Health. The other authors report no actual or potential conflict of interest in relation to this article. 458 The American Journal of Orthopedics® October 2015 www.amjorthopedics.com An Original Study Ascertainment of Cases 998.31-2), wound infection (682.6, 686.9, 891, 891.1-2, 894, Our initial study population, drawn from the period 1998– 894.1-2, 998.5, 998.51, 998.6, 998.83, 998.59), deep vein 2010, consisted of 821,531 patients with a principal ICD-9- thrombosis (453.4, 453.41-2, 453.9), acute myocardial infarc- CM diagnosis of femoral neck fracture (820.0-820.9). To best tion (410, 410.01, 410.11, 410.2, 410.21, 410.3, 410.31, 410.4, capture the typical presentation of hip fracture, we excluded: 410.41, 410.5, 410.51, 410.6, 410.9, 410.91, 997.1), pneumonia ◾◾ Patients with open femoral neck fractures (820.1, 820.3, (480-480.9, 481, 482-482.9, 483, 483.1, 483.8, 484, 484.1, 820.9). 484.3, 484.5-8, 485, 486, 487, 507), pulmonary embolism ◾◾ Patients who did not have open reduction and internal fixa- (415.11, 415.19), sepsis (995.91-2), stroke (997.02), urinary tract tion (ORIF) (79.35), hemiarthroplasty (81.52), closed reduc- infection (599, 997.5), implant infection (996.66-7, 996.69), tion and internal fixation (CRIF) (79.15), internal fixation and incision and débridement (86.04, 86.09, 86.22, 86.28, (78.55), or total hip arthroplasty (THA) (81.51) as their pri- mary surgical procedure. Table 1. Patient Characteristics, by Day of Admissiona ◾◾ Patients admitted from sources other than the emergency department. Characteristic Weekday Weekend P ◾◾ Patients who underwent surgery before admission. Admissions, N 248,097 96,892 ◾◾ Patients whose admission type was not classified as emer- Mean age, y 79.5 78.9 <.0001 gency or urgent. Sex, % .8801 Male 27.0 26.9 Ascertainment of Covariates Female 73.0 73.1 For all patients, we extracted data on exposure of interest, day of Race, % .0723 admission (weekend or weekday), and demographic variables White 75.8 75.5 including age, sex, race (white, black, Hispanic, other, miss- Black 3.4 3.4 ing), and insurance (Medicare, Medicaid, private, other). We Hispanic 3.1 3.0 used the Elixhauser method to determine 30 different comor- Other 2.2 2.1 bidities from ICD-9-CM diagnosis coding16 and sorted patients Missing 15.6 16.0 by total number of comorbidities (0, 1, 2, 3 or 4, ≥5). As has Insurance, % <.0001 17 AJO been done before, we excluded blood loss anemia, coagulopa- Medicare 84.7 83.5 thy, and fluid and electrolyte disorders from this comorbidity Medicaid 2.1 2.1 calculation, as these conditions can be secondary to trauma. We Private 9.9 11.4 also extracted data on the admission itself, including hospital Other 3.4 3.0 region (Northeast, Midwest, South, West), hospital bed size Comorbidities, % <.0001 (small, medium, large), hospital teaching status (nonteaching, 0 12.0 13.1 teaching),DO and hospital location (rural,NOT urban). We used diagno- 1 COPY25.9 25.8 sis codes to categorize fracture location as “not otherwise speci- 2 28.7 28.5 fied” (820.8), intracapsular (820.0), or extracapsular (820.2). 3 or 4 29.0 28.4 ≥5 4.4 4.1 Because of low frequencies, we collapsed 2 race designa- tions (Native American, Asian or Pacific Islander) into the Fracture location, % <.0001 Not otherwise specified 18.7 18.6 “other race” category and 2 insurance designations (self-pay, Intracapsular 30.5 29.4 no charge) into the “other insurance” category. For a substan- Extracapsular 50.8 52.0 tial number of patients, race information was missing, so we Hospital region, % .0202 included “missing” as its own category in analyses. Patients Northeast 26.3 25.9 who were missing data on day of admission, age, sex, insur- Midwest 16.5 16.4 ance, or hospital characteristics were excluded from our final South 49.8 50.1 cohort, as missing frequencies for each variable were small. West 7.5 7.6 Bed size, % .0039 Ascertainment of Outcomes Small 12.2 11.9 For all patients, we extracted data on death status at discharge Medium 27.6 27.3 and length of hospital stay. We log-transformed length of stay Large 60.2 60.8 because of its right skew, assigning the value of 12 hours to Teaching status, % .7330 patients admitted and discharged the same day. Perioperative Nonteaching 64.8 64.8 complications were calculated using ICD-9-CM codes as defined Teaching 35.2 35.2 by a recent study of orthopedics-related complications by Lin Location, % .4970 and colleagues.18 There were 14 possible complications, includ- Rural 16.6 16.5 ing acute renal failure (584.5-9), tachycardia (427), wound Urban 83.4 83.5 hemorrhage (719.15, 998.31-2), wound disruption (998.3, aPercentages may not add exactly to 100 because of rounding. www.amjorthopedics.com October 2015 The American Journal of Orthopedics® 459 Hip Fracture and the Weekend Effect: Does Weekend Admission Affect Patient Outcomes? M. R. Boylan et al 86.3). In our statistical analyses, we examined both the risk of location, hospital region, hospital bed size, hospital teaching having a complicated admission (≥1 perioperative complica- status, and hospital location. We also stratified our study popu- tion) and the risk of having each specific complication. lation by surgical delay in hours (<24, 24-48, 49-72, 73-120, ≥121) and by surgery performed (ORIF, hemiarthroplasty, Statistical Analysis CRIF, internal fixation only, THA, multiple procedures) to To assess similarity between weekend and weekday admissions, examine the effect of weekend admission on mortality, periop- we used the Fisher exact test and χ2 P values.
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