The Tyranny of Distance: How Hospital Transfer Affects Time to Surgery for Hip Fracture Patients.

Introduction In Western Australia, vast distances between hospitals can limit a patient's access to timely surgical intervention. The aim was to examine the effect of patient location on outcomes. Methods Hip fracture data from all operative cases at the major Western Australian hospitals between 2015 and 2019 was retrospectively reviewed. A total of 5691 patients were separated into three groups based on hospital of first presentation - directly to the operative hospital (metropolitan), a hospital less than 2.5 hours by road from the operative centre (outer-metropolitan), or requiring transfer by air (rural). Impact of location on time to surgery, length of stay and 30-day and 120-day mortality was analysed. Results The mean time to surgery was 26.7 hours for metropolitan patients, 37.0 hours for outer-metropolitan, and 42.6 hours for rural patients. Outer-metropolitan patients were less likely to reach surgery within 48 hours than metropolitan patients (80.2% vs 91.5%, p<0.001), with even lower rates for rural patients (66.8%, p<0.001). Acute length of stay was longer for rural patients compared to outer-metropolitan (7.2 vs 5.8 days) and metropolitan patients (5.5 days) (p<0.001). There was no significant difference in 30-day or 120-day mortality for outer-metropolitan or rural patients compared to metropolitan patients despite requiring transfer. However, when considered as a whole group there was an increased 120-day mortality with increased time to surgery. Overall mortality was 8.7% at 30 days and 17.3% at 120 days. Conclusion Patients presenting outside the metropolitan area with a hip fracture have a longer time to surgery and longer length of stay. Delay for outer-metropolitan patients is disproportionately longer than transit time alone and may provide opportunities for improvement.