Does distance to hospital and interhospital transfer negatively impact time to definitive fixation and outcomes in patients with fractured neck of femur in a rural setting?

Objective: This study aims to investigate in patients over 65 with neck of femur (NOF) fractures in Rural Australia, does initial presentation to a peripheral hospital result in a delay to surgery?

Design: Retrospective cohort study.

Setting: Dubba Base Hospital, Trauma Hospital Rural Australia (Modified Monash Model (MMM) 3) and catchment area (MMM 3-7), NSW, Australia.

Participants: The study includes 350 patients over 65, presenting with closed, unilateral NOF fractures who underwent operative management at the operating centre, 203 from peripheral hospitals.

Main outcome measures: Primary outcomes include time to surgery and adherence to recommended timeframes for NOF fixation. Secondary outcomes encompass complications, hospital length of stay and a subgroup analysis to identify causes of surgery delay.

Results: Patients transferred from peripheral hospitals experienced a statistically significant delay in time from presentation to surgery compared to those presenting directly to the operating centre (42 h vs. 24 h, p < 0.001) and were more likely to be outside of current guidelines for NOF fixation within 36 h of presentation (OR 5.1, p < 0.001). There were no differences in mortality at 1 year between the two groups (15% vs. 18%, p = 0.5). On subgroup analysis, distance from the operating centre, time to x-ray and after-hours presentation were associated with increased likelihood of surgery outside of 36 h in the peripheral hospital group.

Conclusion: This study underscores an inequity in service delivery for rural patients with NOF fractures, particularly those requiring transfer. Pre-arrival delays necessitate targeted interventions to address diagnostic service delays, logistical challenges and transport issues in rural health care.