D. Metcalfe1, O. A. Olufajo1, C. K. Zogg1, M. B. Harris2, J. D. Gates1, A. J. Rios Diaz1, A. H. Haider1, A. Salim1 1Harvard Medical School,Center For Surgery And Public Health,Boston, MA, USA 2Brigham & Women’s Hospital,Department Of Orthopedic Surgery,Boston, MA, USA
Introduction:
There is strong evidence to show that level 1 trauma centers (L1TCs) improve outcomes for severely injured patients. However, L1TCs typically host many complex services and manage a high volume of critically unwell patients. It is therefore possible that some clinical pathways will be disrupted in L1TCs and that vulnerable patient groups might compete ineffectively for resources with higher priority cases. There is emerging evidence that appendectomy for acute appendicitis is delayed in L1TCs with an associated increased rate of complications. Studies from the UK and the Netherlands have also reported that the care of older adults with hip fractures may be compromised in new trauma centres.
Our study sought to compare hip fracture outcomes between L1TCs and non-trauma hospitals (NTHs) to determine whether "routine" trauma is underprioritized in mature higher level trauma centers.
Methods:
Hip fracture cases were identified from the California State Inpatient Database (SID) 2007-2011. The California SID captures 98% of hospital admissions and a unique patient identifier permits admissions to be tracked across all hospitals in California. The inclusion criteria were age ≥65 and an operatively treated hip fracture. To minimize selection bias, patients were excluded if they had any other injuries or were transferred between hospitals. Outcomes were analyzed using multivariable logistic regression and generalized linear models for non-normally distributed data, adjusting for patient- (age, sex, race, payer status, Charlson Co-morbidity Index, weekend admission, admission source) and hospital-level (hospital bed size, teaching status) characteristics.
Results:
91,401 hip fracture admissions were identified, 6,468 (7.1%) of which were admitted to L1TCs and 61,896 (67.7%) to NTHs. The remaining patients (25.2%) were treated in lower level trauma centers.
The delay between admission and operation was longer in L1TCs (median 1 day; 90th percentile 3 days) than in NTHs (median 1 day; 90th percentile 2 days, Kruskall-Wallis p<0.001). Within a generalized linear model, operative delay was 0.29 (95% CI 0.08-0.51) days longer in L1TCs relative to NTHs. Length of stay was also prolonged in L1TCs by 0.85 days (95% CI 0.30-1.40). Both the odds of venous thromboembolism (OR 1.45, 95% CI 1.11-1.88) and unplanned 30-day readmission (OR 1.49, 95% CI 1.24-1.80) were higher in L1TCs. There were no mortality differences between L1TCs and NTHs.
Conclusion:
Operative treatment of hip fractures is delayed in L1TCs, which is associated with prolonged length of stay and increased risk of both venous thromboembolism and 30-day hospital readmission. Further work should aim to understand whether these findings can be explained by intense competition for resources (e.g. operating room time) and how clinical pathways for vulnerable populations can be optimized in L1TCs.