Racial Disparity in Time to Surgery and Complications for Hip Fracture Patients

A total of 58,456 patients were included in the study, of which 42,093 (72%) were women and the median age was 84 years (interquartile range, 77–89 years). There were 54,285 white (92.8%), 1,948 African American (3.3%), 1,795 Asian (3.1%), and 428 other patients (0.7%). At baseline, African Americans were significantly younger and more commonly male than whites and Asians (Table 1).

Table 1
Demographics of 58,456 Patients Who Sustained Hip Fractures in the National Surgical Quality Improvement Program Database

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Time to Surgery

African Americans had significantly longer time to surgery (30.4 ± 27.6 hours) than whites (25.8 ± 23.4 hours), Asians (26.5 ± 24.6 hours), and other races (22.7 ± 22.0 hours; all p < 0.001) (Fig. 2). African Americans also had a significantly higher incidence of delayed time to surgery (≥ 48 hours, 28%) compared to whites (21%), Asians (21%), and other races (17%; p < 0.001). After adjusting for comorbidities, sex, age, and type of surgery, Africans Americans had a 43% higher odds of having delayed surgery than whites (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.29–1.58) and Asians (OR, 1.43; 95% CI, 1.22–1.65).

Fig. 2
Time to surgery from hospital presentation for 58,456 patients sorted by race (National Surgical Quality Improvement Program, 2011–2017). Error bars show 95% confidence interval, p < 0.001.

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Perioperative Complications and Mortality

For perioperative complications, African Americans experienced significantly higher rates of reintubation (2.2% vs. 1.4%, p = 0.004), pulmonary embolism (1.3% vs. 0.7%, p = 0.004), failure to wean from ventilator (1.0% vs. 0.6%, p = 0.04), renal insufficiency (0.8% vs. 0.4%, p = 0.008), renal failure (0.7% vs. 0.3%, p = 0.002) and cardiac arrest (1.9% vs. 0.8%, p < 0.001) than all other races (Table 2). On multivariate logistic regression analysis adjusting for age, sex, comorbidities, and type of anesthesia and surgery performed, African Americans had a higher odds of reintubation (OR, 1.5; 95% CI, 1.1–2.1), pulmonary embolism (OR, 1.8; 95% CI, 1.2–2.7), renal insufficiency (OR, 1.9; 95% CI, 1.2–3.3) or failure (OR, 2.2; 95% CI, 1.3–3.9), and cardiac arrest (OR, 2.3; 95% CI, 1.6–3.3). Despite the increased rates of these major perioperative complications, mortality was significantly higher among white patients than African American patients (6.02% vs. 4.41%, p < 0.001). Asian Americans had the lowest mortality rate (3.84%), followed by other (4.21%).

Table 2
Proportion of Patients Experiencing 30-Day Complications in 58,456 Patients Who Sustained Hip Fracture in the United States (National Surgical Quality Improvement Program, 2011–2017)

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In this study assessing the associations of racial disparity with time to surgery and perioperative complications in patients with hip fracture, African Americans had a longer time to surgery and an increased rate of delayed surgery. Despite the higher odds of several major perioperative complications in African Americans, mortality was significantly higher among white patients.

While not novel, these findings support concerns of racial disparity in hip fracture care observed in other studies.4, 6) Similar to our findings of higher mortality among white patients, a California (USA) population-based study of hip fracture patients showed that whites had greater 30-day, 90-day, and 1-year mortality rates than Asian, African American, and Hispanic patients.7) In contrast, in another study investigating outcomes of patients receiving either hemiarthroplasty or total hip arthroplasty, the authors found that Asians were at a greater risk of suffering a major postoperative complication and had higher mortality (0.9%) compared to both whites (0.3%) and African Americans (0.4%).8) However, in an integrated and closed insurance group population for hip fractures, 1-year mortality rates were similar for white (33.7%), black (32.4%), and Hispanics (31.1%), but lower for Asian men (23.1%).9) Our study found similarly low rates of mortality among Asian Americans. Interestingly, despite both increased odds of delayed surgery and higher rates of major complications (pulmonary embolism, renal failure, and cardiac arrest), mortality was lower in African Americans than in whites. It should be noted that NSQIP only tracks 30-day outcomes, and short-term mortality cannot be extrapolated to 1-year mortality rates.

There are certain limitations to this study. First, our analysis lacks data on insurance and socioeconomic status, which may create a level of confounding. However, our analysis controlled for similar baseline patient comorbidities, which may be more indicative of patient vigor and also be predictive of perioperative complications. Our analysis does not provide any stratification by surgery type, as subanalysis would substantially decrease the power of each group. We also only examined 30-day outcomes and mortality, which is a limitation of the NSQIP database. Finally, while the relationship we found between race and hip fracture care remains correlational, further study is needed to determine a direct etiology for delays in surgery.

In summary, we found a significant disparity in both time to surgery and rate of delayed surgery for African Americans compared to whites. African Americans also experienced a higher complication rate than all other races but had a lower rate of mortality than whites. Further study is needed to determine the etiology of this disparity and highlight the need for targeted strategies to help atrisk patient populations.