We found delayed surgery to be more prevalent among minorities. Several previous investigations have demonstrated that delayed surgical stabilization after hip fracture is associated with subsequent complications ranging from decubitus ulcers to thromboembolism and subsequent pulmonary emboli and death (1
). We suspect that the approximately half a day delay among minorities is associated with more complications related to the longer duration of immobilization. However, the clinical impact of the half-day delay should be determined in future studies.
One explanation for the longer preoperative time might be that preoperative management took longer for minorities because of the higher prevalence of undiagnosed and uncontrolled medical conditions previously reported (4
). Consequently, optimal preoperative management of these comorbidities might have taken longer, but such optimal control of medical conditions is recommended to reduce risks of perioperative and postoperative cardiac complications (2
). To address the problem of delayed surgery because of undiagnosed medical conditions, minority patients may need better access to primary care providers who could diagnose and manage these medical problems.
Another potential explanation is delayed transportation to the hospital. The Institute of Medicine reports that minorities experience difficulty with transportation to medical care facilities (17
). A few hours delay in transportation following a morning hip fracture could mean an afternoon admission, thereby delaying testing and preoperative evaluation until the next day. To address transportation problems, patients may need better support systems and/or better access to emergency transportation, especially if they have language barriers to accessing these services.
Addressing these two problems will have benefits beyond reducing morbidity directly related to delayed preoperative time. Other benefits could include expediting access to rehabilitation activities, critical in restoring mobility (15
) and reducing length of hospital stay and hospitalization costs (2
In our sample, minorities were more likely to be male and had a higher number of comorbidities. Our analyses have adjusted for these differences and showed that the longer preoperative time among minorities persisted even after adjusting for these differences and other covariates.
Advantages of using the Medicare Claims data for analyses include access to a large dataset that allows for adjustment for multiple covariates, and the fact that the data reflect current trends in heath care utilization among older Americans and changes in ethnic diversity of the US population. However, several potential limitations should be recognized. Limitations of the dataset could include coding errors associated with use of ICD-9 coding, but ICD-9 coding for hip fracture has been shown to be reliable (19
). Another limitation is the low number of Hispanics and non-Hispanic blacks in our sample, which may have underpowered some analyses in this study. It is likely that fewer Hispanics are qualified for Medicare due to lack of adequate documentation of work history, and the lower average age among Hispanics in the US. In addition, a relatively low sensitivity in identification of Hispanics and non-Hispanic blacks using the race/ethnicity variable in the Medicare dataset may be a factor. However, Arday et al have reported improved sensitivity in race/ethnicity coding in recent years (21
). Overall, the percentage of minorities identified in our study is consistent with that identified by previous studies (19
In summary, our findings indicate longer time to surgery among Hispanics and blacks versus whites, suggesting potential health disparity. Addressing this delay could lead to an improved rate of recovery for older minorities, a rapidly growing segment of the population in the coming years.