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Welch JM, Gomez GI, Chatterjee M, Shapiro LM, Morris AM, Gardner MJ, Sox-Harris AHS, Baker L, Koltsov JCB, Castillo T, Giori N, Salyapongse A, Kamal RN. Contextual Determinants of Time to Surgery for Patients With Hip Fracture. JAMA Netw Open 2023; 6:e2347834. [PMID: 38100104 PMCID: PMC10724766 DOI: 10.1001/jamanetworkopen.2023.47834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/23/2023] [Indexed: 12/18/2023] Open
Abstract
Importance Surgery within 24 hours after a hip fracture improves patient morbidity and mortality, which has led some hospitals to launch quality improvement programs (eg, targeted resource management, documented protocols) to address delays. However, these programs have had mixed results in terms of decreased time to surgery (TTS), identifying an opportunity to improve the effectiveness of interventions. Objective To identify the contextual determinants (site-specific barriers and facilitators) of TTS for patients with hip fracture across diverse hospitals. Design, Setting, and Participants This qualitative mixed-methods study used an exploratory sequential design that comprised 2 phases. In phase 1, qualitative semistructured interviews were conducted with stakeholders involved in hip fracture care (orthopedic surgeons or residents, emergency medicine physicians, hospitalists, anesthesiologists, nurses, and clinical or support staff) at 4 hospitals with differing financial, operational, and educational structures. Interviews were completed between May and July 2021. In phase 2, a quantitative survey assessing contextual determinants of TTS within 24 hours for adult patients with hip fracture was completed by orthopedic surgeon leaders representing 23 diverse hospitals across the US between May and July 2022. Data analysis was performed in August 2022. Main Outcomes and Measures Thematic analysis of the interviews identified themes of contextual determinants of TTS within 24 hours for patients with hip fracture. The emergent contextual determinants were then measured across multiple hospitals, and frequency and distribution were used to assess associations between determinants and various hospital characteristics (eg, setting, number of beds). Results A total of 34 stakeholders were interviewed in phase 1, and 23 surveys were completed in phase 2. More than half of respondents in both phases were men (19 [56%] and 18 [78%], respectively). The following 4 themes of contextual determinants of TTS within 24 hours were identified: availability, care coordination, improvement climate, and incentive structure. Within these themes, the most commonly identified determinants across the various hospitals involved operating room availability, a formal comanagement system between orthopedics and medicine or geriatrics, the presence of a physician champion focused on timely surgery, and a program that facilitates improvement work. Conclusions and Relevance In this study, contextual determinants of TTS within 24 hours for patients with hip fracture varied across hospital sites and could not be generalized across various hospital contexts because no 2 sites had identical profiles. As such, these findings suggest that guidance on strategies for improving TTS should be based on the contextual determinants unique to each hospital.
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Affiliation(s)
- Jessica M. Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Duke University School of Medicine, Durham, North Carolina
| | - Giselle I. Gomez
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Stanford University School of Medicine, Stanford, California
| | - Maya Chatterjee
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Human Development and Family Studies, Colorado State University, Fort Collins
| | - Lauren M. Shapiro
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Orthopaedic Surgery, University of California, San Francisco
| | - Arden M. Morris
- Department of Surgery, Stanford University, Stanford, California
| | - Michael J. Gardner
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Alex H. S. Sox-Harris
- Department of Surgery, Stanford University, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Laurence Baker
- Department of Health Policy, Stanford University, Stanford, California
| | - Jayme C. B. Koltsov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Tiffany Castillo
- Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, California
| | - Nicholas Giori
- Department of Orthopaedic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Aaron Salyapongse
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Robin N. Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Anoushiravani AA, Posner AD, Gheewala RA, Feng JE, Chisena EN. A 7-year perspective on femoral neck fracture management in New York State-Do Level 1 trauma centers provide better care? Injury 2023:S0020-1383(23)00361-3. [PMID: 37183086 DOI: 10.1016/j.injury.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/20/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Patients with femoral neck fractures are at a substantial risk for medical complications and all-cause mortality. Given this trend, our study aims to evaluate postoperative outcomes and the economic profile associated with femoral neck fractures managed at level-1 (L1TC) and non-level-1-trauma centers (nL1TC). METHODS The SPARCS database was queried for all geriatric patients sustaining atraumatic femoral neck fractures within New York State between 2011 and 2017. Patients were then divided into two cohorts depending on the treating facility's trauma center designation: L1TC versus nL1TC. Patient samples were evaluated for trends and relationships using descriptive analysis, Student's t-tests, and Chi-squared. Multivariable linear-regressions were utilized to assess the effect of trauma center designation and potential confounders on patient mortality and inpatient healthcare expenses. RESULTS In total, 44,085 femoral neck fractures operatively managed at 161 medical centers throughout New York during a 7-year period. 4,974 fractures were managed at L1TC while 39,111 were treated at nL1TC. Following multivariate regression analysis, management at L1TC was the most significant cost driver, resulting in an average increased cost of $6,330.74 per fracture. CONCLUSION Our results suggest that femoral neck fractures treated at L1TC have more comorbidities, higher in-hospital mortality, longer LOS, and greater hospital costs.
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Affiliation(s)
- Afshin A Anoushiravani
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA.
| | - Andrew D Posner
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Rohan A Gheewala
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - James E Feng
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, 3535 West 13 Mile Road, Suite 742, Royal Oak, MI 48073, USA
| | - Ernest N Chisena
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
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Tyas B, Lukic J, Harrison J, Singisetti K. A comparative study of hip fracture care and outcomes in major trauma centres versus trauma units. Injury 2022; 53:1455-1458. [PMID: 35168760 DOI: 10.1016/j.injury.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/28/2022] [Accepted: 02/05/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is good evidence to support that major trauma networks significantly reduce morbidity and mortality in severely injured patients. However, following the introduction of major trauma centres (MTCs) in England in 2012, early concerns were raised regarding the effect on hip fracture patients. The aim of our study was to review data from the National Hip Fracture Database for fractured neck of femur (FNOF) patients, comparing patient outcomes between MTCs and trauma units (TUs), and the national regions of the UK. METHODS NHFD data from 2018 for all hospitals in England, Wales and NI was collected using the charts and dashboards available online. We recorded data for the following outcomes: time to surgery, acute hospital length of stay, overall hospital length of stay, discharge to original residence within 120 days, crude 30-day mortality and adjusted 30-day mortality. We conducted a one-way ANOVA test to calculate statistical differences for each outcome measure by MTC vs TU and then separately for the regions of the UK divided into England, Wales and Northern Ireland (NI). RESULTS Data for 175 hospitals are included in this study; 22 of which were MTCs. The total number of operative cases were 65,848. 9668 of these occurred in MTC compared to 56,180 in TUs. This equates to an annual average of 439 per MTC and 367 per TU. Despite this, there was no statistically significant difference observed in all outcomes for MTC vs TU. Patients in NI waited longer for their surgery (60.3 h, p < 0.001), whilst patients in Wales had the longest overall hospital length of stay (31.6 days, p < 0.001). However, there was no difference in patients' crude 30-day mortality (p = 0.480) or adjusted 30-day mortality (p = 0.191). CONCLUSION These findings are reassuring for MTCs in England. We found no evidence to suggest that FNOF patients are treated inferiorly, or have worse outcomes, at MTCs vs TUs. FNOF patients in NI waited longer for their surgery but this did not have any significant difference on 30-day mortality rates. The care of FNOF patients in NI may warrant further study.
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Affiliation(s)
- Ben Tyas
- Core Surgical Trainee, Health Education North East, United Kingdom.
| | - John Lukic
- Clinical Fellow, Gateshead Health NHS Foundation Trust, United Kingdom
| | - John Harrison
- Trauma and Orthopaedic Surgeon, Gateshead Health NHS Foundation Trust, United Kingdom
| | - Kiran Singisetti
- Trauma and Orthopaedic Surgeon, Gateshead Health NHS Foundation Trust, United Kingdom
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Levi AR, Coste M, Warshowsky E, Shah NV, Suneja N, Schwartz JM, Roudnitsky V. Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation. Geriatr Orthop Surg Rehabil 2022; 13:21514593221076614. [PMID: 35242395 PMCID: PMC8886300 DOI: 10.1177/21514593221076614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Approximately 300 000 hip fractures occur annually in the USA in patients
>65 years old. Early intervention is key in reducing morbidity and
mortality. Our institution implemented a collaborative hip fracture
protocol, streamlining existing processes to reduce time to OR (TTO) and
hospital length of stay (LOS). Our aim was to determine if this protocol
improved these outcomes. Study Design We conducted a retrospective cohort study using our level-1 trauma center’s
trauma registry, comparing outcomes for patients >60 years old with
isolated hip fractures pre-and post-hip protocol implementation in May 2018.
Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes
included LOS and postoperative complications. Univariate analysis was done
using chi-square and T-test. Results We identified 176 patients with isolated hip fractures: 69 post- and 107
pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs
57h; P = .013) and patients had fewer postoperative
complications (9 vs 23%; P = .016) despite post-protocol
patients being more likely to have diabetes (42 vs 27%, P
< .05), elevated BMI (22 vs 25; P < .001), and to be
current smokers (9 vs 2%; P < .05). LOS and in-hospital
mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%;
P = .402). Post-protocol patients were more likely to
go to the OR within 24hrs of presentation (39 vs 16%; P
< .001) and to go straight from ED to OR (32 vs 4%; P
< .001). Conclusion TTO, LOS, and postoperative complications for isolated hip fracture patients
were lower post-protocol. Though not all statistically significant, this
trend indicates that the protocol was helpful in improving hip fracture
outcomes but may require further improvement and institution-wide
education.
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Affiliation(s)
- Amelia R Levi
- Department of Surgery, SUNY Downstate Health & Sciences University, Kings County NYC Health & Hospitals, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Marine Coste
- Department of Surgery, SUNY Downstate Health & Sciences University, Kings County NYC Health & Hospitals, Brooklyn, NY, USA
| | - Ethan Warshowsky
- Department of Surgery, SUNY Downstate Health & Sciences University, Kings County NYC Health & Hospitals, Brooklyn, NY, USA
| | - Neil V Shah
- Department of Orthopaedic Surgery, SUNY Downstate Health & Sciences University, Kings County NYC Health and Hospitals, Brooklyn, NY, USA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Kings County NYC Health and Hospitals, Brooklyn, NY, USA
| | - Jeffrey M Schwartz
- Department of Orthopaedic Surgery, Kings County NYC Health and Hospitals, Brooklyn, NY, USA
| | - Valery Roudnitsky
- Department of Surgery, SUNY Downstate Health & Sciences University, Kings County NYC Health & Hospitals, Brooklyn, NY, USA
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Hourston GJ, Barrett MP, Khan WS, Vindlacheruvu M, McDonnell SM. New drug, new problem: do hip fracture patients taking NOACs experience delayed surgery, longer hospital stay, or poorer outcomes? Hip Int 2020; 30:799-804. [PMID: 31020851 DOI: 10.1177/1120700019841351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Neck of femur fractures are common in the comorbid, often anticoagulated, elderly. Non-vitamin K antagonist oral anticoagulants (NOACs) may affect patient outcomes. We aimed to evaluate whether hip fracture patients admitted on warfarin or NOAC therapy were at risk of operative delay, prolonged length of stay, or increased mortality. METHODS We collected data for 845 patients admitted to our centre between October 2014 and December 2016. Multivariable linear regression analysis was performed to test the association between warfarin and NOAC therapy on time to surgery and length of stay. Variables in the regression model were age, sex, admission AMTS, pre-fracture mobility, ASA score, fracture type, and operation type. Fisher's exact test was used to evaluate whether warfarin or NOAC therapy delayed surgery beyond 36 or 48 hours, or decreased 30-day, 6-month, or 12-month survival. RESULTS Time to surgery was delayed in anticoagulated patients (p = 0.028). NOAC therapy was independently associated with increased time to surgery beyond 36 hours (p = 0.001), although not beyond 48 hours (p = 0.355), whereas warfarin therapy was not associated with either. Anticoagulation did not increase length of stay (p = 0.331). Warfarin therapy significantly reduced 30-day survival (p = 0.007), but NOAC therapy did not (p = 0.244). Neither warfarin nor NOAC therapy affected further survival. CONCLUSIONS NOAC therapy delays time to surgery beyond the NHS England 'Best Practice Tariff' in hip fracture patients. We aim to prospectively investigate long-term outcomes. Without a NOAC antidote, policy must change to ensure time-appropriate surgery for patients on NOACs. Preoperative involvement of the haematology team is essential.
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Affiliation(s)
| | - Michael P Barrett
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Wasim S Khan
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | | | - Stephen M McDonnell
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
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Abstract
Aims This study explores the reported rate of surgical site infection (SSI) after hip fracture surgery in published studies concerning patients treated in the UK. Methods Studies were included if they reported on SSI after any type of surgical treatment for hip fracture. Each study required a minimum of 30 days follow-up and 100 patients. Meta-analysis was undertaken using a random effects model. Heterogeneity was expressed using the I2 statistic. Risk of bias was assessed using a modified Newcastle-Ottawa Scale (NOS) system. Results There were 20 studies reporting data from 88,615 patients. Most were retrospective cohort studies from single centres. The pooled incidence was 2.1% (95% confidence interval (CI) 1.54% to 2.62%) across ‘all types’ of hip fracture surgery. When analyzed by operation type, the SSI incidences were: hemiarthroplasty 2.87% (95% CI 1.99% to 3.75%) and sliding hip screw 1.35% (95% CI 0.78% to 1.93%). There was considerable variation in definition of infection used, as well as considerable risk of bias, particularly as few studies actively screened participants for SSI. Conclusion Synthesis of published estimates of infection yield a rate higher than that seen in national surveillance procedures. Biases noted in all studies would trend towards an underestimate, largely due to inadequate follow-up.
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Affiliation(s)
- James Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joon Soo Ha
- The Royal College of Surgeons of England, London, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Cuesta-Peredo D, Tarazona-Santabalbina FJ, Borras-Mañez C, Belenguer-Varea A, Avellana-Zaragoza JA, Arteaga-Moreno F. Estimate of the Costs Caused by Adverse Effects in Hospitalised Patients Due to Hip Fracture: Design of the Study and Preliminary Results. Geriatrics (Basel) 2018; 3:E7. [PMID: 31011055 DOI: 10.3390/geriatrics3010007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 01/02/2023] Open
Abstract
Introduction: Hip fracture is a health problem that presents high morbidity and mortality, negatively influencing the patient’s quality of life and generating high costs. Structured analysis of quality indicators can facilitate decision-making, cost minimization, and improvement of the quality of care. Methods: We studied 1571 patients aged 70 years and over with the diagnosis of hip fracture at Hospital Universitario de la Ribera in the period between 1 January 2012 and 31 December 2016. Demographic, clinical, functional, and quality indicator variables were studied. An indirect analysis of the costs associated with adverse events arising during hospital admission was made. A tool based on the “Minimum Basic Data Set (CMBD)” was designed to monitor the influence of patient risk factors on the incidence of adverse effects (AE) and their associated costs. Results: The average age of the patients analysed was 84.15 years (SD 6.28), with a length of stay of 8.01 days (SD 3.32), a mean preoperative stay of 43.04 h (SD 30.81), and a mortality rate of 4.2%. Likewise, the percentage of patients with AE was 41.44%, and 11.01% of patients changed their cost as a consequence of these AEs suffered during hospital admission. The average cost of patients was €8752 (SD: 1,864) and the average cost increase in patients with adverse events was €2321 (SD: 3,164). Conclusions: Through the analysis of the main clinical characteristics and the indirect estimation of the complexity of the patients, a simple calculation of the average cost of the attention and its adverse events can be designed in patients who are admitted due to hip fracture. Additionally, this tool can fit the welfare quality indicators by severity and cost.
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Metcalfe D, Olufajo OA, Zogg CK, Gates JD, Weaver MJ, Harris MB, Rios-Diaz AJ, Haider AH, Salim A. Are Older Adults With Hip Fractures Disadvantaged in Level 1 Trauma Centers? Med Care 2016; 54:616-22. [PMID: 26974676 DOI: 10.1097/MLR.0000000000000535] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Large regional hospitals achieve good outcomes for patients with complex conditions. However, recent studies have suggested that some patient groups might not benefit from treatment in higher-level trauma centers. OBJECTIVE To test the hypothesis that older adults with isolated hip fractures experience delayed surgical treatment and worse clinical outcomes when treated in higher-level trauma centers. RESEARCH DESIGN Retrospective cohort study using a statewide longitudinal database that captured 98% of inpatients within California (2007-2011). SUBJECTS All older adults (aged 65 y and above) admitted with an isolated hip fracture who did not require interhospital transfer. MEASURES Days to operation, length of stay, inhospital mortality, 30-day risk of unplanned readmission, 30-day venous thromboembolism, decubitus ulcers, and pneumonia. RESULTS There were 91,401 patients, 6.1% of whom were treated in a level 1 trauma center (L1TC), 17.7% in a level 2 trauma center (L2TC), and 70.2% in a nontrauma center (NTC). Within multivariable logistic and generalized linear regression models, patients treated in L1TCs underwent surgery later (predicted mean difference: 0.30 d; 95% CI, 0.08-0.53), had prolonged inpatient stays (0.99 d, 0.40-1.59), and had higher odds of both 30-day readmission (aOR=1.62; 95% CI, 1.35-1.93) and venous thromboembolism (aOR=1.32, 1.01-1.74) relative to NTCs. There were no differences in mortality, decubitus ulcers, or pneumonias. L2TCs were not different from NTCs across any of the measured outcomes. CONCLUSIONS Older adults with hip fractures may be disadvantaged in L1TCs. Further research should aim to develop our understanding of this disparity to ensure that all patient groups benefit from the resources and expertise available within these hospitals.
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Thorne K, Johansen A, Akbari A, Williams JG, Roberts SE. The impact of social deprivation on mortality following hip fracture in England and Wales: a record linkage study. Osteoporos Int 2016; 27:2727-2737. [PMID: 27098537 PMCID: PMC4981619 DOI: 10.1007/s00198-016-3608-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 03/01/2016] [Indexed: 12/02/2022]
Abstract
UNLABELLED We used routine hospital data to investigate whether socially deprived patients had an increased risk of dying following hip fracture compared with affluent patients. We found that the most deprived patients had a significantly increased risk of dying at 30, 90 and 365 days compared with the most affluent patients. INTRODUCTION To identify whether social deprivation has any effect on mortality risk after emergency admission with hip fracture and to determine whether any increased mortality observed among deprived groups was associated with patient and hospital-related factors. METHODS We used routine, linked hospital inpatient and mortality data for emergency admissions with a hip fracture in both England and Wales between 2004 and 2011. Mortality rates at 30, 90 and 365 days were reported. Logistic regression was used to identify any significant increases in mortality with higher levels of social deprivation and the influence of other risk factors on any increased mortality among the most deprived group. RESULTS Mortality rates at 30, 90 and 365 days were 9.3, 17.4 and 29.0 % in England and 8.3, 16.1 and 27.9 % in Wales. Social deprivation was significantly associated with increased mortality in the most deprived quintile compared with the least deprived quintile at 30, 90 and 365 days in England (OR = 1.187, 1.185 and 1.154, respectively) and at 90 and 365 days in Wales (1.135 and 1.203). There was a little interaction between deprivation and other risk factors influencing 30- and 365-day mortality except for patient age, pre-fracture residence and hospital size. CONCLUSIONS We demonstrated a positive association between social deprivation and increased mortality at 30 days post-admission for hip fracture in both England and Wales that was still evident at 90 and 365 days. We found little influence of other factors on social inequalities in mortality risk at 30 and 365 days post-admission.
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Affiliation(s)
- K Thorne
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP, UK.
| | - A Johansen
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
- Trauma Unit, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - A Akbari
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - J G Williams
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - S E Roberts
- Swansea University Medical School, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
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Sargazi N, El-gawad A, Narayan B, Bell D, Shanks L, Nayagam S, Graham K. A full time regional ortho-plastic unit; initial results. J Plast Reconstr Aesthet Surg 2016; 69:572-3. [DOI: 10.1016/j.bjps.2015.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 11/25/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
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Metcalfe D, Gabbe BJ, Perry DC, Harris MB, Ekegren CL, Zogg CK, Salim A, Costa ML. Quality of care for patients with a fracture of the hip in major trauma centres. Bone Joint J 2016; 98-B:414-9. [DOI: 10.1302/0301-620x.98b3.36904] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip. Patients and Methods All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days. Results There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals. Conclusion These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. Take home message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip. Cite this article: Bone Joint J 2016;98-B:414–19.
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Affiliation(s)
| | - B. J. Gabbe
- Monash University, 99
Commercial Road, Melbourne, Vic
3004, Australia
| | - D. C. Perry
- University of Liverpool, Liverpool, L12
2AP, UK
| | - M. B. Harris
- Brigham Women’s Hospital, 75
Francis Street, Boston, MA
02115, USA
| | - C. L. Ekegren
- Monash University, 99
Commercial Road, Melbourne, Vic
3004, Australia
| | - C. K. Zogg
- Harvard Medical School, One
Brigham Circle, Boston, MA
02115, USA
| | - A. Salim
- Harvard Medical School, One
Brigham Circle, Boston, MA
02115, USA
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Metcalfe D, Olufajo O, Rios-Diaz AJ, Haider A, Havens JM, Nitzschke S, Cooper Z, Salim A. Are appendectomy outcomes in level I trauma centers as good as we think? J Surg Res 2016; 202:239-45. [PMID: 27229096 DOI: 10.1016/j.jss.2016.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy. METHODS An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007-2011). All patients with an ICD-90-CM diagnosis of "acute appendicitis" (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors. RESULTS There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14-0.36]), stayed in hospital longer (0.83 d [0.36-1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13-2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes. CONCLUSIONS Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.
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Affiliation(s)
- David Metcalfe
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts
| | - Olubode Olufajo
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Joaquim M Havens
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Stephanie Nitzschke
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts.
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