To the Editor—I read with interest the paper by Liu et al1 that focused on elderly patients undergoing hip fracture surgery, showing that the longer the delay to surgery (>2 days), the higher the risk of death. Despite the potential limitations correctly identified by the authors, the introduction of the Key Performance Indicator in Hong Kong in 2008 undoubtedly led to an overall improved quality of life for these patients.

Liu et al1 acknowledge that data from health care utilisation databases lack important information about functional status or other geriatric indexes. I agree that the need to further stratify the population according to their clinical complexity or co-morbidity may prompt specific strategies for high-risk subjects. Nonetheless I suggest that the key role of functional status and its effect on risk of death be considered. It was previously shown that delaying hip surgery for more than 2 days in the subgroup of subjects with pre-existing disability carries the highest risk of 1-year mortality.2 In other words, in elderly patients, disability impacts mortality risk more than surgical delay, even after adjusting for age, gender, co-morbidity, drugs, and presence of delirium.3

Although Italy4 and Hong Kong have distinct populations, life expectancy and access to health care services are similar, at least when one considers the most densely inhabited areas. Consistent with the previous experience,5 stabilisation of medical conditions may sometimes be a necessity.1 It was also speculated that elderly patients with pre-existing disabilities, who are among the frailest individuals, Hong Kong Med J 2017;23:542 DOI: 10.12809/hkmj176916 are presumably those who will benefit most from early surgery.2

1. Liu SK, Ho AW, Wong SH. Early surgery for Hong Kong Chinese elderly patients with hip fracture reduces short-term and long-term mortality. Hong Kong Med J 2017;23:374-80. Crossref

2. Bellelli G, Mazzola P, Corsi M, et al. The combined effect of ADL impairment and delay in time from fracture to surgery on 12-month mortality: an observational study in orthogeriatric patients. J Am Med Dir Assoc 2012;13:664.e9-664.e14.

3. Mazzola P, Bellelli G, Broggini V, et al. Postoperative delirium and pre-fracture disability predict 6-month mortality among the oldest old hip fracture patients. Aging Clin Exp Res 2015;27:53-60. Crossref

4. Mazzola P, Rimoldi SM, Rossi P, et al. Aging in Italy: The Need for New Welfare Strategies in an Old Country. Gerontologist 2016;56:383-90. Crossref

5. Mazzola P, De Filippi F, Castoldi G, Galetti P, Zatti G, Annoni G. A comparison between two co-managed geriatric programmes for hip fractured elderly patients. Aging Clin Exp Res 2011;23:431-6. Crossref