Abstract
INTRODUCTION: Surgery is the preferred treatment for hip fracture in older people. However, a proportion of patients with hip fracture do not receive surgery. There is a lack of contemporary evidence describing this patient population and what their associated outcomes are. We aimed to describe the variation in non-operative management and its outcomes around the world. METHODS: We performed a systematic review and meta-analysis of older people presenting to hospital with hip fracture, comparing those with and without surgery for non-operative proportions, mortality and other outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale. We performed a random effects meta-analysis with adjustment for clustering. RESULTS: Of 4437 screened studies, 185 were included from 172 separate cohorts, 44 countries, six continents and involving 10,763,994 patients. The overall proportion of non-operative management was 8.4% (95%CI 7.2-9.7%) with wide within-country and regional variation. There was no consistent association of non-operative management proportions with the admission characteristics of sex, fracture type or patient ethnicity. Non-operative management was associated with a greater relative risk of death at all time points. Risk of bias was generally low except for the expected confounding by indication. DISCUSSION: Non-operative management of hip fracture is relatively common, but there is wide variation that is unexplained by differences in patient characteristics. The evidence is limited by incomplete reporting of patient characteristics and outcomes, and a lack of controlled studies even in the highest risk populations. Further work is needed to understand this decision-making process.