ORIGINAL ARTICLE Time from admission to surgery in Polish patients with hip fractures: temporal trends in the last decade and association with duration of hospitalization and in­‑hospital mortality Kamil Polok1, Zbigniew Pilecki2 , Halina Kutaj­‑Wąsikowska3,4 , Barbara Kutryba3,4 , Rosa Sunol5,6,7, Grzegorz Pilecki2 , Jacek Górka1, Jakub Fronczek1, Wojciech Szczeklik1 1 Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland 2 CMS Sports Medicine Center, Zabrze, Poland 3 Polish Society for Quality Promotion in Health Care, Kraków, Poland 4 National Center for Quality Assessment in Health Care (NCQA), Kraków, Poland 5 Avedis Donabedian Research Institute (FAD), Barcelona, Spain 6 Autonomous University of Barcelona, Barcelona, Spain 7 The Health Services Research on Chronic Patients Network (REDISSEC), Barcelona, Spain Key words Abstract healthcare, hip Introduction Hip fracture is an important cause of morbidity and mortality among elderly patients world‑ fractures, patient wide. It poses a particular challenge for healthcare systems with limited financial and human resources. outcome assessment, Objectives The aim of the study was to assess factors associated with the length of hospital stay quality indicators and in­‑hospital mortality, focusing on the time from admission to surgery. The secondary goal was to assess temporal trends in the intervals of admission to surgery between 2010 and 2011 and in 2019. Editorial Patients and methods This was a cross­‑sectional study enrolling patients aged 65 years or older who underwent surgery for hip fracture between January 2010 and October 2011 in 12 Polish hospitals. by López Castro, Demographic and clinical data, dates of hospital admission and surgery as well as information about see p. 481 in­‑hospital death were gathered. We additionally searched the databases of the same 12 hospitals for patients hospitalized due to hip fracture between January and June 2019 and recorded the dates of admission and surgery. Results We included 381 patients who underwent surgery in 2010 and 2011 and 761 patients hospi‑ talized in 2019. In a multivariable analysis, including age, sex, and diagnosis of dementia, we observed association between time from admission to surgery and higher in­‑hospital mortality and longer hospital stay. There was a decrease in proportion of patients undergoing surgery within 2 days from admission (52.8% vs 44.3%; P = 0.007) between 2010 to 2011 and in 2019. Conclusions In­‑hospital mortality and length of hospitalization were associated with time from admis‑ Correspondence to: Prof. Wojciech Szczeklik, MD, PhD, sion to surgery in patients undergoing surgery for hip fracture. We observed an alarming trend towards Department of Intensive Care and an increase in the admission–surgery interval. Perioperative Medicine, Jagiellonian University Medical College, ul. Skawińska 8, 31-066 Kraków, Poland, phone: +48 12 430 52 66, Introduction Hip fractures are an important healthcare systems.3,4 Advanced age, lower body­ email: wojciech.szczeklik@uj.edu.pl Received: March 9, 2020. cause of morbidity, mortality, and emergency sur­ ‑mass index, tendency for falls, and physical in­ Revision accepted: April 30, 2020. geries among geriatric patients in the developed activity are well­‑established risk factors for hip Published online: May 7, 2020. countries and their incidence is projected to tri­ fractures.5 Mortality in this population is affected Pol Arch Intern Med. 2020; ple by 2050.1,2 This condition leads to a signif­ by several factors (male sex, dementia, and histo­ 130 (6): 506-511 doi:10.20452/pamw.15342 icant functional impairment and therefore de­ ry of cardiovascular disease) according to the re­ Copyright by the Author(s), 2020 creases patient quality of life and is a burden for cently published meta­‑analysis.6 506 POLISH ARCHIVES OF INTERNAL MEDICINE 2020; 130 (6) What’s new? protocol, each center was obliged to stop recruit­ ment after enrolling 35 patients. Hip fractures remain one of the most important challenges for contemporary The inclusion criteria were: 1) age 65 years or medicine. According to current guidelines, prompt surgery is a crucial fac‑ older; 2) diagnosis of hip fracture; 3) surgery for tor in improvement of patient outcomes. In this study, we showed that both hip fracture during index hospitalization. length of hospital stay and mortality were affected by time passing from Exclusion criteria was transfer from a different admission to surgery, independent of patients’ age, sex, and diagnosis of hospital for treatment after the initial diagnosis. dementia. Moreover, we assessed temporal trends between years 2010 and Additionally, in order to assess temporal chang­ es in clinical practice, we searched databases of 2011, and in 2019 in terms of the interval between admission and procedure participating hospitals for patients admitted be­ for hip fracture. Alarmingly, the analysis showed a decrease in the propor‑ tween January and June 2019 for hip fracture tion of patients undergoing surgery within 2 days from admission. What is using the International Classification of Diseases, more, the absolute value of this important healthcare quality measure would Ninth Revision (ICD­‑9) and International Statistical put Poland in one of the last places in Europe. These results should not only Classification of Diseases, Tenth Revision (ICD­‑10) cause unease among the Polish healthcare providers, but also trigger prompt codes (8200–1, 8202–3, 8208–9 and S72.0, S72.1, action to reverse this negative trend. S72.2 respectively) in order to assess the time from hospital admission to surgery. The protocol complied with the Declaration of Helsinki and its amendments. Signing of the writ­ Hip fractures pose a serious challenge for ten informed consent to participate in the study the Polish healthcare system with estimated age­ was not required. The DUQuE project was approved ‑standardized rate of 181/100 000, putting Po­ by the bioethics committee at the Health Depart­ land on the 44th place out of 63 countries ana­ ment of the Government of Catalonya. The approv­ lyzed in a study by Kanis et al.7 Unfortunately, ob­ al of local bioethical committees was not required. served trends suggest that the hip fracture rate in the Polish population will continuously rise Data collection The research staff gathered de­ to reach approximately 470/100 000 in the next mographic (sex, age) and clinical data (history of 30 years.8 The Polish healthcare system is partic­ hypertension, coronary artery disease, conges­ ularly vulnerable to an increase in the number of tive heart failure, diabetes mellitus, kidney dis­ procedures due to limited workforce and finan­ ease, liver disease, chronic obstructive pulmonary cial resources. disease or asthma, dyslipidemia, peripheral ar­ Early surgery after hip fracture is considered tery disease and dementia) based on interviews one of the most important factors influencing with the patients, family members, and available patient outcomes, based on the results of several medical records. Additionally, dates of fracture, observational studies.9 This is reflected in prac­ admission, surgery and discharge or in­‑hospital tice guidelines which recommend performing death were collected. In case of patients hospital­ surgery on the day of, or the day after, the ad­ ized in 2019, only dates of birth, admission, and mission.10 Percentage of patients operated for surgery were recorded. hip fracture within 2 days varies significantly in Europe and ranges from 96% in Norway and Statistical analysis Categorical variables were Denmark to 46% in Latvia. Unfortunately, sim­ presented as counts (percentage) and compared ilar data on surgery timing in the Polish popu­ using the χ2 test, while continuous variables lation are missing in the recent Organization were presented as mean (SD) or median (inter­ for Economic Co­‑operation and Development quartile range) and compared using the t test or (OECD) report.11 the Mann–Whitney test depending on their dis­ In this cross­‑sectional study, we aimed to as­ tribution. A multivariable analysis was performed sess factors associated with in­‑hospital mortal­ in the entire study group using logistic regression ity and hospitalization length among Polish pa­ to assess association between in­‑hospital mortal­ tients who suffered hip fracture. Our secondary ity and time from admission to surgery, adjust­ aim was to assess the temporal changes in qual­ ed for age, sex, and diagnosis of dementia, while ity of care, reflected by time from admission to linear regression was performed in order to eval­ surgery, in this population. uate the relation between length of hospital stay and time from admission to surgery, adjusted for Patients and methods Design, setting, and age, sex, and diagnosis of dementia. Variables oth­ population of the study The study was a part of er that time from admission to surgery (age, sex, a DUQuE (Deepening our Understanding of Qual­ dementia) were selected based on available liter­ ity Improvement in Europe) project—an interna­ ature, reviewers’ comments, and authors’ knowl­ tional multi­level cross­‑sectional study, designed edge. Assumptions of normality of residuals and to assess relationship between quality manage­ homoscedasticity were evaluated and multicol­ ment and patient outcomes in the European linearity was assessed using the variance infla­ Union.12 This substudy included patients under­ tion factors. This was a complete­‑case analysis. going hip fracture surgery between January 2010 Statistical analyses were performed with RStu­ and October 2011 in 12 teaching and nonteaching dio, packages rms and ggplot2 (RStudio, PBC, hospitals in Poland. In accordance with the study Boston, Massachusetts, United States). ORIGINAL ARTICLE Quality of care in patients undergoing hip fracture surgery in Poland 507 TABLE 1 Study group characteristics Characteristics Total Survivors Nonsurvivors P value (n = 381) (n = 295) (n = 86) Demographic Age, y, median (IQR) 80.3 (75.6–85.7) 80.5 (75.7–85.4) 79.9 (74.6–86.4) 0.43 Male sex 109 (28.6) 79 (26.8) 30 (34.9) 0.14 Comorbidities Coronary artery disease 58 (15.2) 43 (18.5) 15 (27.3) 0.15 Chronic heart failure 110 (28.9) 86 (35.3) 24 (43.6) 0.24 Hypertension 221 (58) 175 (64.1) 46 (65.7) 0.8 COPD / asthma 36 (9.4) 29 (11.9) 7 (12.3) 0.93 Chronic kidney disease 14 (3.7) 10 (3.9) 4 (5.7) 0.49 Dementia 66 (17.3) 42 (19.1) 24 (35.8) 0.004 Diabetes mellitus 116 (30.4) 86 (29.2) 30 (34.9) 0.31 Time intervals Fracture to surgery, d, median (IQR) 3 (1–5) 2 (1–5) 5 (3–8) <0.001 Admission to surgery, d, median (IQR) 2 (1–4) 2 (1–3) 4 (3–7) <0.001 Surgery time, min, median (IQR) 63 (50–90) 60 (50–90) 70 (50–95) 0.17 Hospitalization time, d, median (IQR) 11 (9–14) 11 (9–13) 12 (7–19) 0.4 Data are presented as number (percentage) of patients unless otherwise indicated. Abbreviations: COPD, chronic obstructive pulmonary disease; IQR, interquartile range Results Clinical characteristics of the study group Assessment of temporal changes between in 2010–2011 The study group consisted of 381 2010 and 2011 and in 2019 showed a signifi­ patients who underwent surgery for hip fracture. cant increase in time from admission to surgery The median age was 80.3 (75.6–85.7) years and (2 vs 3 days; P = 0.002) and decrease in propor­ 109 study participants (28.6%) were men. We ob­ tion of patients undergoing surgery within 2 days served high prevalence of hypertension (58%), di­ from admission (52.8% vs 44.3%; P = 0.007). Pa­ abetes (30.4%), and chronic heart failure (28.9%). tients hospitalized in 2019 were significantly old­ Patients who died (86; 22.6%) during hospital­ er compared with those undergoing surgery in ization had significantly higher prevalence of de­ 2010 and 2011 (83 vs 80.3; P = 0.007). mentia (35.8% vs 19.1%; P = 0.004), longer frac­ ture to surgery time (5 vs 2 days; P <0.001), and Discussion In this cross­‑sectional study based admission to surgery time (4 vs 2 days; P <0.001) on the Polish population of patients aged 65 years compared with survivors. In the study group, or older who underwent surgery for hip fracture, 201 patients (52.8%) underwent surgery with­ we observed that both mortality and length of in 2 days from admission. Detailed information hospital stay are associated with time interval can be found in Table 1 and Figure 1 . between admission to the hospital and surgery. Moreover, we observed a decrease in the propor­ Multivariable analysis Multivariable analyses tion of patients undergoing surgery within 2 days showed that time from admission to surgery was from admission between 2011 and 2019. associated with in­‑hospital mortality (odds ratio, The Polish population of patients with hip 2.567; 95% CI, 1.811–3.762; P <0.001) and dura­ fracture is comparable with these in studies per­ tion of hospitalization (odds ratio, 0.575; 95% CI, formed in other countries; patients are usually 0.502–0.649; P <0.001). Presented effects are for elderly women with significant comorbidities.7 the square root of time from admission to sur­ An analysis of baseline clinical and demographic gery. All results were adjusted for age, sex and differences between survivors and nonsurvivors diagnosis of dementia. Odds ratios with 95% CI showed higher prevalence of dementia among and β­‑coefficients with 95% CI are presented in the latter, which corroborates data from several Table 2 and Table 3 , respectively. previous reports.13,14 The most crucial factor influencing mortality Time from admission to surgery in 2019 We iden­ after hip surgery was time between hospital ad­ tified 761 patients at a median (IQR) age of 83 mission and surgery. This association was con­ (75–87) years hospitalized in 2019, who under­ firmed in both univariable and multivariable anal­ went the surgical procedure for hip fracture. ysis which included age, sex, and diagnosis of de­ The median (IQR) time from admission to sur­ mentia. There are numerous observational stud­ gery was 3 (1–5) days. Among them, 337 pa­ ies showing positive impact of early surgery on tients (44.3%) were operated within 2 days from outcomes of patients with hip fracture, and there­ admission. fore, guidelines suggest performing surgery not 508 POLISH ARCHIVES OF INTERNAL MEDICINE 2020; 130 (6) TABLE 2 Multivariable analysis of association between mortality and admission­– higher priority. Prolonged hospital stay is known surgery time, adjusted for sex, age, and diagnosis of dementia not only to increase the risk of complications, for Factor OR 95% CI P value example, hospital­‑acquired infections and deliri­ um, but also to markedly increase the cost of med­ Admission­–surgery timea 2.567 1.811–3.762 <0.001 ical care, which is of particularly great importance Agea 1.061 0.601–2.006 0.839 in the limited­‑resource healthcare environment.19 Sexb 0.970 0.499–1.937 0.929 This work should urge the officials to establish Dementia 1.522 0.737–3.053 0.244 a national registry of patients with hip fractures. Such registries already exist in countries such as a Continuous variables were square root transformed in the process of model United Kingdom, Australia, New Zealand, Swe­ development. den, Norway, Denmark. It would offer a unique b Male sex was used as a comparator. opportunity to continuously evaluate the effec­ tiveness of Polish healthcare system in this cru­ Abbreviations: OR, odds ratio cial matter, and therefore could lead to a signifi­ cant improvement in the quality of care.20 Anoth­ TABLE 3 Multivariable analysis of association between hospitalization lengtha and er important step in the improvement of quality admission–surgery time, adjusted for sex, age, and diagnosis of dementia of care in this population should be further de­ Factor β­‑coefficient 95% CI P value velopment of geriatric orthopedic surgery with a particular focus on interdisciplinary approach to Admission­–surgery time a 0.575 0.502–0.649 <0.001 hip fracture patients. This idea encompasses tight Agea –0.008 –0.145 to 0.130 0.911 cooperation of several specialists (eg, orthopedic Sexb 0.087 –0.067 to 0.240 0.267 surgeon, geriatrician, anesthesiologist, dietician, Dementia 0.154 –0.012 to 0.320 0.068 physiotherapists) aimed at optimization of care in geriatric patients who suffered from hip frac­ a Continuous variables were square root transformed in the process of model ture. It includes multiple elements, for example, development. precise geriatric assessment, optimization of fit­ b Male sex was used as a comparator. ness for surgery, identification of individual goals for rehabilitation, continuous geriatric review, co­ operation with other medical services (falls pre­ later than on the next day after admission.15 Due vention, primary care, social services) and palli­ to observational design of the studies, the quali­ ative care, if necessary. Such approach proved to ty of evidence remains low; however, the results be effective in reducing number of complications, of the first randomized controlled trial concern­ shortening hospitalization time, and achieve­ ing this topic (Hip Fracture Accelerated Surgical ment of walking ability from before the injury.21-23 Treatment And Care Track; HIP ATTACK; Clini­ The additional analysis of differences between calTrials.gov identifier, NCT02027896) with al­ years 2010 and 2011 and the first half of 2019 most 3000 enrolled patients have just been pub­ shows some interesting, yet concerning, results. lished.16 -18 The study showed that accelerated sur­ We observed a decrease in the proportion of pa­ gery (goal time to procedure was 6 hours) com­ tients undergoing surgery within 2 days of admis­ pared with standard care did not result in an sion (52.8% vs 44.3%). This discrepancy may be improvement in mortality and other major com­ due to differences in the methodology of acquired plications at 90 days after procedure. Mortality data (cross­‑sectional vs retrospective); however, in the HIP­‑ATTACK trial was twice lower (9% in it more probably reflects the decreased accessi­ the interventional group, 10% in the standard care bility to hip fracture repair surgery. Moreover, group, 22.6% in our study). However, important­ observed difference in age could also be associ­ ly, the median time from the diagnosis to surgery ated with increased time from admission to sur­ was much shorter (6 hours in the interventional gery as a result of a possibly higher number of co­ group and 24 hours in the standard care group) morbidities, in particular dementia. Another po­ compared with median admission to surgery time tential explanation would be that some clinicians accounting to 2 days in our study group. do not consider hip fracture a medical emergen­ Our study revealed some disturbing data re­ cy. Moreover, receiving the decision for anesthe­ garding the quality of care provided by the Pol­ sia and surgery takes a long time and leads to de­ ish healthcare system. Only around 50% of hip lay of the surgery. fracture patients underwent surgery within 2 We are aware of several limitations of our days of hospital admission, which would place Po­ study. Firstly, due to the relatively low num­ land in one of the last positions in the aforemen­ ber of patients and events, we were unable to tioned OECD report.11 Obviously, only a nation­ include some other important variables into wide study could provide reliable data on the ac­ the model, for example, the study was under­ tual situation; however, we believe that hitherto powered to reliably assess the importance of inter­ acquired results are already alarming enough and ‑center variability and to evaluate differences thus require a closer investigation. The results of in outcomes depending on hospital’s reference our secondary analysis, showing a positive asso­ level. These variables would probably affect de­ ciation between admission to surgery time and scribed association of time from admission to longer hospital stay, should grant this issue even surgery with in­‑hospital mortality and duration ORIGINAL ARTICLE Quality of care in patients undergoing hip fracture surgery in Poland 509 Figure 1 Histogram of time from admission to surgery in survivors (grey) and nonsurvivors (blue). Dashed lines represent 0.2 Proportion of patients median values for each group. 0.1 0 0 5 10 15 20 25 Time from admission to surgery, d of hospitalization as higher reference level cen­ and JG were involved in literature search. All authors contributed to data in‑ terpretation and manuscript preparation. ters usually have access to more experienced cli­ Conflict of interest None declared. nicians, better equipment, wider range of special­ Open access This is an Open Access article distributed under the terms ist consultants, and larger number of intensive of the Creative Commons Attribution­‑NonCommercial­‑ShareAlike 4.0 Inter‑ care unit beds, which in turn could significantly national License (CC BY­‑NC­‑SA 4.0), allowing third parties to copy and re‑ distribute the material in any medium or format and to remix, transform, and influence both in­‑hospital mortality and length build upon the material, provided the original work is properly cited, distrib‑ of hospital stay. Secondly, lack of post­‑discharge uted under the same license, and used for noncommercial purposes only. For commercial use, please contact the journal office at pamw@mp.pl. follow­‑up deprives us of some potentially inter­ How to cite Polok K, Pilecki Z, Kutaj­‑Wąsikowska H, et al. Time from esting observations. Thirdly, data about comor­ admission to surgery in Polish patients with hip fractures: temporal trends bidities were collected solely on the basis of in­ in the last decade and association with duration of hospitalization and in­ ‑hospital mortality. Pol Arch Intern Med. 2020; 130: 506-511. doi:10.20452/ terviews with patients and families, as well as pamw.15342 available medical records, which could lead to some imprecision, particularly in terms of diag­ References nosis of dementia. Also, data on mortality and 1 Johnell O, Kanis JA. An estimate of the worldwide prevalence, mor‑ duration of hospitalization among patients un­ tality and disability associated with hip fracture. Osteoporos Int. 2004; 15: dergoing surgery in 2019 would provide an in­ 897-902.  teresting opportunity to reliably assess recent 2 Gullberg B, Johnell O, Kanis JA. World­‑wide projections for hip fracture. Osteoporos Int. 1997; 7: 407-413.  trends in these crucial outcomes, particularly 3 Leslie WD, O’Donnell S, Jean S, et al. Trends in hip fracture rates in Can‑ in the context of potentially significant impact ada. JAMA. 2009; 302: 883-889.  of difference in age between samples from 2010 4 Bhandari M, Swiontkowski M. Management of acute hip fracture. N Engl and 2011, and 2019. Moreover, the retrospective J Med. 2017; 377: 2053-2062.  design of the study is inherently associated with 5 Marks R. Hip fracture epidemiological trends, outcomes, and risk fac‑ tors, 1970-2009. Int J Gen Med. 2010; 3: 1-17.  some important constraints (eg, lack of informa­ 6 Liu Y, Wang Z, Xiao W. Risk factors for mortality in elderly patients with tion about prehospital functional status and care­ hip fractures: a meta­‑analysis of 18 studies. Aging Clin Exp Res. 2018; 30: giver situation), which could influence the quali­ 323-330.  ty of presented data. 7 Kanis JA, Odén A, McCloskey EV, et al. A systematic review of hip frac‑ ture incidence and probability of fracture worldwide. Osteoporos Int. 2012; In this cross­‑sectional study, based on the Pol­ 23: 2239-2256.  ish population of patients undergoing hip frac­ 8 Wilk R, Skrzypek M, Kowalska M, et al. The 13­‑year observation of hip ture surgery, around half of patients underwent fracture in Poland – worrying trend and prognosis for the future. Aging Clin Exp Res. 2018; 30: 61-69.  index procedure later than recommended by clin­ 9 Simunovic N, Devereaux PJ, Sprague S, et al. Effect of early surgery af‑ ical guidelines. We confirmed the association be­ ter hip fracture on mortality and complications: systematic review and meta­ tween in­‑hospital mortality, length of hospital ‑analysis. CMAJ. 2010; 182: 1609-1616.  stay, and time from admission to surgery. Finally, 10 National Institute for Health and Care Excellence (NICE). The manage‑ ment of hip fracture in adults. Natl Clin Guidel Cent. 2017; 1-628. the analysis of recent trends suggests a decrease 11 OECD/European Union (2018). Waiting times for hip fracture surgery. in proportion of patients operated within 2 days In Health at a Glance: Europe 2018: State of Health in the EU Cycle. OECD of hospital admission. Publishing; 2018. 12 Secanell M, Groene O, Arah OA, et al. Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospi‑ Article information tal quality management in seven countries. Int J Qual Health Care. 2014; Acknowledgments The DUQuE project was funded by the Europe‑ 26: 5-15. an Community – Seventh Framework Programme FP7/2007–2013 (Grant 13 Ruggiero C, Bonamassa L, Pelini L, et al. Early post­‑surgical cognitive Agreement number 24188; to HK-W) dysfunction is a risk factor for mortality among hip fracture hospitalized old‑ Contribution statement HK­‑W, WS, ZP, BK, RS, GP, JG, and JF de‑ er persons. Osteoporos Int. 2017; 28: 667-675.  signed the study. HK­‑W, ZP, BK, RS, and GP were involved in data collection. 14 Khan MA, Hossain FS, Ahmed I, et al. Predictors of early mortality after KP, WS, and JF performed statistical analysis. KP, HK­‑W, WS, ZP, BK, RS, GP, hip fracture surgery. Int Orthop. 2013; 37: 2119-2124.  510 POLISH ARCHIVES OF INTERNAL MEDICINE 2020; 130 (6) 15 Moja L, Piatti A, Pecoraro V, et al. Timing matters in hip fracture sur‑ gery: patients operated within 48 hours have better outcomes. A meta­ ‑analysis and meta­‑regression of over 190 000 patients. PLoS One. 2012; 7: e46175.  16 Borges FK, Bhandari M, Patel A, et al. Rationale and design of the hip fracture accelerated surgical treatment and care track (hip attack) trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients. BMJ Open. 2019; 9: 1-8. 17 Hip Fracture Accelerated Surgical Treatment and Care Track (HIP AT‑ TACK) Investigators. Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial. CMAJ. 2014; 186: E52­‑E60.  18 Borges FK, Bhandari M, Guerra­‑Farfan E, et al. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, ran‑ domised, controlled trial. Lancet. 2020; 6736: 1-11. 19 Rosman M, Rachminov O, Segal O, Segal G. Prolonged patients’ In­ ‑Hospital Waiting Period after discharge eligibility is associated with in‑ creased risk of infection, morbidity and mortality: a retrospective cohort analysis. BMC Health Serv Res. 2015; 15: 246.  20 Johansen A, Golding D, Brent L, et al. Using national hip fracture reg‑ istries and audit databases to develop an international perspective. Injury. 2017; 48: 2174-2179.  21 Riemen AH, Hutchison JD. The multidisciplinary management of hip fractures in older patients. Orthop Trauma. 2016; 30: 117-122.  22 Smith TO, Hameed YA, Cross JL, et al. Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Da‑ tabase Syst Rev. 2015: CD010569.  23 Dawe H. Modernising Hip Fracture Anaesthesia. Open Orthop J. 2017; 11: 1190-1199.  ORIGINAL ARTICLE Quality of care in patients undergoing hip fracture surgery in Poland 511