Delay in surgery, risk of hospital-treated infections and the prognostic impact of comorbidity in hip fracture patients. A Danish nationwide cohort study, 2005–2016

Figures & data

Table 1 Patient characteristics according to delay of surgery

	Delay >12 hrs				Delay >24 hrs				Delay >48 hrs
	No, ≤12		Yes, >12		No, ≤24		Yes, >24		No, ≤48		Yes, >48
	N	%	N	%	N	%	N	%	N	%	N	%
Total	14,616	20	57,904	80	45,152	62	27,368	38	67,291	93	5,229	7
Patient-related variables
Sex
Female	10,394	71	41,450	72	32,482	72	19,362	71	48,226	72	3,618	69
Male	4,222	29	16,454	28	12,670	28	8,006	29	19,065	28	1,611	31
Age, in years
65–74	2,918	20	10,988	19	8,827	20	5,079	19	12,940	19	966	18
74–79	2,329	16	9,442	16	7,224	16	4,547	17	10,828	16	943	18
80–84	3,114	21	12,920	22	9,824	22	6,210	23	14,867	22	1,167	22
85–89	3,347	23	13,633	24	10,441	23	6,539	24	15,741	23	1,239	24
90+	2,908	20	10,921	19	8,836	620	4,993	18	12,915	19	914	17
Body Mass Index
<18.5	1,290	9	4,970	8	3,967	9	2,293	8	5,854	9	406	8
≥18.5–24.9	6,693	46	26,335	45	20,704	46	12,324	45	30,764	46	2,264	43
≥25.0–29.9	2,804	19	11,471	20	9,008	20	5,267	19	13,209	20	1,066	20
≥30	779	5	3,221	6	2,472	5	1,528	6	3,709	5	291	6
Unknown	3,050	21	11,907	21	9,001	20	5,956	22	13,755	20	1,202	23
Charlson Comorbidity Index
Low (0)	6,016	41	23,301	40	18,730	41	10,587	39	27,395	41	1,922	37
Medium (1–2)	5,787	40	23,550	41	18,056	40	11,281	41	27,110	40	2,227	42
High (3+)	2,813	19	11,053	19	8,366	19	5,500	20	12,786	19	1,080	21
Alcohol-related disease
None	14,079	96	55,897	79	43,574	97	26,402	96	64,899	96	5,077	97
1 or more	537	4	2,007	3	1,578	3	966	4	2,392	4	152	3
Marital status
Unmarried	10,196	70	40,959	71	31,842	71	19,313	71	47,506	71	3,649	70
Married	4,420	30	16,945	29	13,310	29	8,055	29	19,785	29	1,580	30
Fracture-related variables
Type of fracture
Femoral neck	7,272	50	30,947	53	23,202	51	15,017	55	35,209	52	3,010	58
Per-/subtrochanter	7,344	50	26,957	47	21,950	49	12,351	45	32,082	48	2,219	42
Type of surgery
Osteosynthesis	11,185	76	39,038	67	32,399	72	17,824	65	47,085	70	3,138	60
Hemi/total Arthroplasty	3,431	24	18,866	33	12,753	28	9,544	35	20,206	30	2,091	40
Year of surgery
2005–2006	2,363	16	9,528	16	6,772	15	5,119	19	10,785	16	1,106	21
2007–2008	2,342	16	10,346	18	7,189	16	5,499	20	11,558	17	1,130	22
2009–2010	2,178	15	10,136	18	7,239	16	5,075	19	11,263	17	1,051	20
2011–2012	2,516	17	9,849	17	7,886	18	4,479	16	11,567	17	798	15
2013–2014	2,652	18	9,435	16	8,312	18	3,775	14	11,479	17	608	12
2015–2016	2,565	18	8,610	15	7,754	17	3,421	12	10,639	16	536	10
Medication use before surgery
Corticosteriods
Non-users	13,054	89	51,919	90	40,548	90	24,425	89	60,322	90	4,651	89
Former users	615	4	2,485	4	1,888	4	1,212	4	2,875	4	225	4
Current users	947	7	3,500	6	2,716	6	1,731	6	4,094	6	353	7
Anti-osteoporotic medication
Non-users	13,046	89	52,216	90	40,553	90	24,709	90	60,501	90	4,761	91
Former users	393	3	1,492	3	1,223	3	662	3	1,764	3	121	2
Current users	1,177	8	4,196	7	3,376	7	1,997	7	5,026	7	347	7
Non-Steroidal Anti-Inflammatory Drugs
Non-users	11,499	79	45,197	78	35,461	79	21,235	78	52,646	78	4,050	77
Former users	1,479	10	6,002	10	4,633	10	2,848	10	6,928	10	553	11
Current users	1,638	11	6,705	12	5,058	11	3,285	12	7,717	12	626	12
Oral anti-coagulants
Non-users	7,933	54	29,546	51	24,288	54	13,191	48	35,146	52	2,333	45
Former users	1,403	10	5,719	10	4,287	9	2,835	10	6,538	10	584	11
Current users	5,280	36	22,639	39	16,577	37	11,342	42	25,607	38	2,312	44
Statins
Non-users	11,120	76	43,767	76	34,191	76	20,696	76	50,955	76	3,932	75
Former users	873	6	3,674	6	2,772	6	1,775	6	4,186	6	361	7
Current users	2,623	18	10,463	18	8,189	18	4,897	18	12,150	18	936	18
Selective Serotonin Reuptake Inhibitors
Non-users	11,095	76	44,351	77	34,446	76	21,000	77	51,448	76	3,998	76
Former users	608	4	2,321	4	1,865	4	1,064	4	2,727	4	202	4
Current users	2,913	20	11,232	19	8,841	20	5,304	19	13,116	20	1,029	20
Antibiotics
Non-users	7,554	52	30,521	53	23,664	52	14,411	53	35,296	53	2,779	53
Former users	3,487	24	13,972	24	10,807	24	6,652	24	16,220	24	1,239	24
Current users	3,575	24	13,411	23	10,681	24	6,305	23	15,775	23	1,211

Table 2 Incidence rate and hazard ratios (HR with 95% confidence interval (CI) for the 3 specific hospital-treated infections within 0–30 days following hip fracture surgery. HRs were adjusted for age, sex, comorbidity burden (CCI), type of fracture and year of surgery. When stratifying for comorbidity, the CCI-variable was left out of the analysis

0-30 days
	In total			Stratified
	Number of UTI	Incidence per 1000 person years (ci)	All	CCI low	CCI medium	CCI high
			HR (ci)	HR (ci)	HR (ci)	HR (ci)
≤12 hours	830	2.11 (1.97 – 2.26)	1.00	1.00	1.00	1.00
>12 hours	3,375	2.16 (2.09 – 2.24)	1.03 (0.95 – 1.11)	1.06 (0.93 – 1.20)	1.00 (0.89 – 1.13)	1.03 (0.87 – 1.21)
≤24 hours	2,597	2.13 (2.05 – 2.21)	1.00	1.00	1.00	1.00
>24 hours	1,608	2.19 (2.09 – 2.30)	1.03 (0.97 – 1.10)	1.07 (0.96 – 1.18)	1.00 (0.91 – 1.10)	1.03 (0.90 – 1.17)
≤48 hours	3,915	2.16 (2.09 – 2.23))	1.00	1.00	1.00	1.00
>48 hours	290	2.06 (1.83 – 2.31)	0.96 (0.85 – 1.08)	1.04 (0.85 – 1.27)	0.95 (0.79 – 1.14)	0.89 (0.69 – 1.14)
0-30 days
	In total			Stratified
	Number of pneumonia	Incidence per 1000 person years (ci)	All	CCI low	CCI medium	CCI high
			HR (ci)	HR (ci)	HR (ci)	HR (ci)
≤12 hours	754	1.90 (1.77 – 2.04)	1.00	1.00	1.00	1.00
>12 hours	3,051	1.93 (1.87 – 2.00)	1.04 (0.96 – 1.12)	1.20 (1.03 – 1.40)	0.92 (0.82 – 1.04)	1.09 (0.93 – 1.27)
≤24 hours	2,315	1.88 (1.80 – 1.95)	1.00	1.00	1.00	1.00
>24 hours	1,490	2.01 (1.91 – 2.12)	1.09 (1.02 – 1.16)	1.11 (0.98 – 1.26)	1.12 (1.02 – 1.23)	1.02 (0.90 – 1.15)
≤48 hours	3,528	1.93 (1.86 – 1.99)	1.00	1.00	1.00	1.00
>48 hours	277	1.95 (1.73 – 2.19)	1.03 (0.91 – 1.17)	1.06 (0.84 – 1.35)	1.00 (0.83 – 1.20)	1.05 (0.84 – 1.32)
0-30 days
	In total			Stratified
	Number of reoperations due to infection	Incidence per 1000 person years (ci)	All	CCI low	CCI medium	CCI high
			HR (ci)	HR (ci)	HR (ci)	HR (ci)
≤12 hours	38	0.09 (0.07 – 0.13)	1.00	1.00	1.00	1.00
>12 hours	215	0.13 (0.12 – 0.15)	1.41 (1.00 – 1.99)	1.48 (0.84 – 2.60)	1.25 (0.73 – 2.14)	1.59 (0.76 – 3.36)
≤24 hours	148	0.12 (0.10 – 0.14)	1.00	1.00	1.00	1.00
>24 hours	105	0.14 (0.11 – 0.17)	1.17 (0.91 – 1.50)	0.87 (0.57 – 1.34)	1.38 (0.92 – 2.05)	1.35 (0.81 – 2.25)
≤48 hours	226	0.12 (0.11 – 0.14)	1.00	1.00	1.00	1.00
>48 hours	27	0.18 (0.13 – 0.27)	1.51 (1.01 – 2.26)	0.93 (0.41 – 2.14)	1.53 (0.82 – 2.88)	2.36 (1.19 – 4.69)

Abbreviations: DMHFR, Danish Multidisciplinary Hip Fracture Registry; h, hours; CCI, Charlson Comorbidity Index, HR, hazard ratio; CI, confidence interval; UTI, urinary tract infection; BMI, body mass index; NSAIDs, Non Steroidal Anti-Inflammatory Drugs (NSAIDs); SSRI, Selective Serotonin Reuptake Inhibitor.; ICD, International Classification of Diseases revision 10.

Any hospital-treated (inpatient or outpatient) infections, collected from The Danish National Patient Register.

Infection	ICD revision 10 diagnose codes
Miscellaneous bacterial infections	A20-A38, A42-A44, A48-A49, A65-A79
Bacteremia	A49.9, A39.4
Sepsis	A40-A41,A32.7, A54.86, A02.1, A22.7, A26.7, A42.7, A28.2B
Abscess	A54.1, D73.3, E06.0A, E23.6A, E32.1, G06, G07, H00.0A, H05.0A, H44.0A, H60.0, J34.0A, J36, J38.3D, J38.7G, J39.0, J39.1, J39.8A, J85.1, J85.2, J85.3, K04.6, K04.7, K11.3, K12.2, K13.0A, K14.0A, K20.9A, K35.3A, K35.3B, K57.0, K57.2, K57.4, K57.8, K61, K63.0, K65.0, K75.0, K81.0A, K85.8A, L02, L05.0, L05.9, M60.8A, M86.8A, M86.9A, N15.1, N34.0, N41.2, N45.0, N48.2, N49.2A, N61.9A, N61.9B, N70.0A, N70.0B, N71.0A, N73.0A, N73.0B, N73.2A, N73.2B, N73.3A, N73.5A, N73.8A, N73.8C, N75.1, N76.4, N76.8A, Except: A54.1B, B43.0, B43.8, B43.9, K57.0B, K57.0C, K57.2B, K57.2C, K57.4A, K65.0M, K65.0N, K65.0O, K65.0P
Skin infections	A46, H01.0, H03, H60.0, H60.1, H60.2, H60.3, H62, K12.2, K13.0, K61, M72.6, L01, L08.0, L08.1,
Cellulitis	L03
Other skin infections	J34.0, L00, L02, L04, L05, L06, L07, L30.3, L73.8
Eye infections	H00, H01.0, H03.0, H03.1, H04.3, H05.0, H06.1, H10, H13.0, H13.1, H15.0, H19.1, H19.2, H22.0, H32.0, H44.0, H44.1
Ear infections	H60, H61.0, H62.0, H62.1, H62.2, H62.3, H65, H66, H67.0, H67.1, H68, H70, H73.0, H75.0, H83.0, H94.0 Except: H60.4, H60.4A, H605, H60.5B, H60.8, H608.A, H65.2, H65.3, H65.4, H65.4C, H66.1, H66.2, H66.3, H68.1, H70.1, H70.8
Central Nervous System infections	G00-07 (except meningococcal disease)
Meningitis	G00, G01, G02, G03, A32.1, A39.0, A17.0, A20.3, A54.8D, A02.2C
Gastrointestinal infections:	A00, A01, A02, A03, A04, A05, A09
Intra-abdominal infection	K35, K37, K57.0, K57.2, K57.4, K57.8, K61, K63.0, K65.0, K65.9, K67, K75.0, K75.1, K80.0, K80.3, K80.4, K81.0, K81.9, K83.0, K85.9
Heart infections (acute rheumatic fever, infectious pericarditis or myocarditis, endocarditis):	I00-I02, I30.1, I32.0, I33, I38, I40.0, I39.8, B37.6
Upper respiratory tract infection	J00-J06, J36, J39.0, J39.1
Pneumonia	J12, J13, J14, J15, J16.0, J17, J18
Other lower-respiratory tract infections:	J20-J22, J44.0, J85.1, J86, J20-J22, J34.0, J35.0, J38.3C, J38.3D, J38.7B, J38.7F, J38.7G Except: J34.0E, J34.0F, J34.0G, J34.0H
Urinary tract infections	N10, N11, N12, N15.1, N15.9, N30, N33.0, N34, N39.0, N08.0, N13.6, N16.0, N28.8D, N28.8E, N28.8F, N29.0, N29.1 Except: N30.1, N30.2, N30.4
Sexually transmitted diseases	A50-A64
Male genital infections	N41, N45, N48.1, N48.2, N49, N51.1, N51.2
Female pelvic infections	N70-77
Septic arthritis, osteomyelitis, myositis	M00, M01, M86, M63.0, M63.2
Infectious complications of procedures, catheters etc.	T80.2, T81.4, T82.6, T82.7, T83.5, T83.6, T84.5, T84.6, T84.7, T85.7, T88.0, T89.9
Other infections or sequelae	B90-B99, K04.0, K05.2
Reoperation due to infection Procedures	ICD revision 10 diagnose codes
NFW69: Do not require combination with ICD-10 codes but can be combined with ICD-10 code	T84.5, T84.6, T84.7
NFS 0-99: In combination with ICD-10 code
NFU 0-99: In combination with ICD-10 code
NFC20-99: If NFB is primary operation type, in combination with ICD-10 code
Diagnoses included in Charlton comorbidity index Disease	ICD revision 10 diagnose codes
Myocardial infarction	I21;I22;I23
Congestive heart failure	I50; I11.0; I13.0; I13.2
Peripheral vascular disease	I70; I71; I72; I73; I74; I77
Cerebrovascular disease	I60-I69; G45; G46
Dementia	F00-F03; F05.1; G30
Chronic pulmonary disease	J40-J47; J60-J67; J68.4; J70.1; J70.3; J84.1; J92.0; J96.1; J98.2; J98.3
Connective tissue disease	M05; M06; M08; M09;M30;M31;M32; M33; M34; M35; M36; D86
Ulcer disease	K22.1; K25-K28
Mild liver disease	B18; K70.0-K70.3; K70.9; K71; K73; K74; K76.0
Diabetes, type1 and type2	E10.0, E10.1; E10.9; E11.0; E11.1; E11.9
Hemiplegia	G81; G82
Moderate to severe renal disease	I12; I13; N00-N05; N07; N11; N14; N17-N19; Q61
Diabetes with end organ damage	E10.2-E10.8; E11.2-E11.8
Any tumor	C00-C75
Leukemia	C91-C95
Lymphoma	C81-C85; C88; C90; C96
Moderate to severe liver disease	B15.0; B16.0; B16.2; B19.0; K70.4; K72; K76.6; I85
Metastatic solid tumor	C76-C80
AIDS	B21-B24
Alcoholism-related disease Disease	ICD revision 10 diagnose codes
Alcohol related disorder	F10
Alcohol induced chronic pancreatitis	K86.0
Finding of alcohol in blood	R78.0
Toxic effect of alcohol	T51
Alcoholic gastritis without bleeding	K29.2
Alcoholic polyneuropathy	G62.1
Alcoholic myopathy	G72.1
Degeneration of nervous system due to alcohol	G31.2
Alcoholic cardiomyopathy	I42.6
Drug use prior to the hip fracture Drug	Anatomical Therapeutic Chemical classification system - ATC-codes
Systemically absorbed glucocorticoids	H02BX
Statins	C10AA01, C10AA02, C10AA03 C10AA04, C10AA05, C10AA06,
Anti-osteoporosis medicine Anti-osteoporosis medicine	M05BA01, B05BB01, M05BA02, M05BA03, M05BA04, M05BB03, M05BB05, M05BA06, M05BA07, M05BB02, M05BB04, M05BX04, M05BX03, G03XC01, H05AA02
Non-steroidal Anti-Inflammatory Drugs	M01AH01, M01AH, M01AH03, M01AH05, M01AC05, M01AB05, M01ACO6, M0A1
Oral anti-coagulants	B01AB, B01AX, A01AD, B01AA, B01AE07, B01AF01, B01AF02, B01AF03, B01AC, N02BA01, N02BA51
Selective Serotonin Reuptake Inhibitors	N06AB03, N0GAB04, N06AB05, N06AB06, N06AB08, N06AB10
Antibiotics	J01X, J05X

The distribution of diseases from the Charlson index according to delay in surgery. All primary and secondary diagnoses included in the CCI and registered in relation to hospitalizations and outpatient visits over a ten-year period before the hip fracture form the basis for having (yes) og not having (no) a specific comorbid disease at the time of surgery.

	Delay > 12 hours				Delay >24 hours				Delay >48 hours
	No, ≤12		Yes, >12		No, ≤24		Yes, >24		No, ≤48		Yes, >48
Myocardial infarction
Yes	804	5	3,140	5	2,360	5	1,584	6	3,610	5	334	6
No	13,812	95	54,764	95	42,792	95	25,784	94	63,681	95	4,895	94
Congestive heart failure
Yes	1,227	8	5,382	9	3,712	8	2,897	11	5,970	9	639	12
No	13,389	92	52,522	91	41,440	92	24,471	89	61,321	91	4,590	88
Peripheral vascular disease
Yes	1,145	8	4,575	8	3,426	8	2,294	8	5,259	8	461	9
No	13,471	92	53,329	92	41,726	92	25,074	92	62,032	92	4,768	91
Cerebrovascular disease
Yes	2,558	18	10,732	19	8,010	18	5,280	19	12,201	18	1,089	21
No	12,058	82	47,172	81	37,142	82	22,088	81	55,090	82	4,140	79
Dementia
Yes	1,433	10	5,611	10	4,381	10	2,663	10	6,566	10	478	9
No	13,183	90	52,293	90	40,771	90	24,705	90	60,725	90	4,751	91
Chronic pulmonary disease
Yes	1,756	12	7,261	13	5,411	12	3,606	13	8,344	12	673	13
No	12,860	88	50,643	87	39,741	88	23,762	87	58,947	88	4,556	87
Connective tissue disease
Yes	666	5	2,754	5	2,087	5	1,333	5	3,146	5	274	5
No	13,950	95	55,150	95	43,065	95	26,035	95	64,145	95	4,955	95
Ulcer disease
Yes	837	6	3,271	6	2,512	6	1,596	6	3,771	6	337	6
No	13,779	94	54,633	94	42,640	94	25,772	94	63,520	94	4,892	94
Mild liver disease
Yes	162	1	635	1	478	1	319	1	738	1	59	1
No	14,454	99	57,269	99	44,674	99	27,049	99	66,553	99	5,170	99
Diabetes I and II
Yes	1,181	8	4,975	9	3,783	8	2,373	9	5,697	8	459	9
No	13,435	92	52,929	91	41,369	92	24,995	91	61,594	92	4,770	91
Hemiplegia
Yes	35	0	147	0	102	0	80	0	165	0	17	0
No	14,581	100	57,757	100	45,050	100	27,288	100	67,126	100	5,212	100
Moderate to severe renal disease
Yes	545	4	2,166	4	1,626	4	1,085	4	2,484	4	227	4
No	14,071	96	55,738	96	43,526	96	26,283	96	64,807	96	5,002	96
Diabetes with end organ damage
Yes	649	4	2,845	5	2,127	5	1,367	5	3,197	5	297	6
No	13,967	96	55,059	95	43,025	95	26,001	95	64,094	95	4,932	94
Any tumor
Yes	2,234	15	8,344	14	6,590	15	3,988	15	9,824	15	754	14
No	12,382	85	49,560	86	38,560	85	23,380	85	57,467	85	4,475	86
Leukemia
Yes	72	0	283	0	215	0	140	1	329	0	26	0
No	14,544	100	57,621	100	44,937	100	27,228	99	66,962	100	5,203	100
Lymphoma
Yes	123	1	489	1	371	1	241	1	571	1	41	1
No	14,493	99	57,415	99	44,781	99	27,127	99	66,720	99	5,188	99
Moderate to severe liver disease
Yes	74	1	231	0	198	0	116	0	277	0	28	1
No	14,542	99	57,673	100	44,963	100	27,252	100	67,014	100	5,201	99
Metastatic solid tumor
Yes	290	2	801	1	688	2	403	1	1,005	1	86	2
No	14,326	98	57,103	99	44,464	98	26,965	99	66286	99	5,143	98
AIDS
Yes	3	0	13	0	9	0	7	0	15	0	1	0
No	14,613	100	57,981	100	45,143	100	27,361	100	67,276	100	5,228	100