Pay for performance and hip fracture outcomes: an interrupted time series and difference-in-differences analysis in England and Scotland

Aims

Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control.

Materials and Methods

We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay.

Results

There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay.

Conclusion

This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England.

Cite this article: Bone Joint J 2019;101-B:1015–1023.

Validation of a prospective cohort study of older adults with hip fractures

Aims

This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures.

Patients and Methods

The characteristics of patients recruited into the WHiTE cohort study were compared with those treated at WHiTE hospitals during the same timeframe and submitted to the National Hip Fracture Database (NHFD).

Results

Patients recruited to WHiTE were more likely to be admitted from their own home (83.5% vs 80.2%; p < 0.001) and to have a higher median Abbreviated Mental Test Score (AMTS) (9 (interquartile range (IQR) 6 to 10) vs 9 (IQR 5 to 10); p < 0.001) than those who were not recruited. In terms of WHiTE cohort generalizability, participating hospitals included a greater proportion of Major Trauma Centres (47.8% vs 7.8%) and large hospitals (997 (IQR 873 to 1290) vs 707 (459 to 903) beds) with high-volume Emergency Departments (median annual attendances of 43 981 (IQR 37 147 to 54 385) vs 35 964 (IQR 26 229 to 50 551)). However, there were few differences in baseline characteristics between patients in the WHiTE cohort and those recorded in the NHFD.

Conclusion

There is evidence of a weak selection bias towards recruiting fitter patients within the WHiTE cohort, which will help to put into context the findings of future studies. We conclude that the patients within the WHiTE cohort are representative of the national population of older adults with hip fractures throughout England, Wales, and Northern Ireland. Cite this article: Bone Joint J 2019;101-B:708–714.

Temporal trends and survivorship of total hip arthroplasty in very young patients

Aims

The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years.

Patients and Methods

A descriptive observational study was undertaken using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man between April 2003 and March 2017. All patients aged ≤ 20 years at the time of THA were included and the primary outcome was revision surgery. Descriptive statistics were used to summarize the data and Kaplan–Meier estimates calculated for the cumulative implant survival.

Results

A total of 769 THAs were performed in 703 patients. The median follow-up was 5.1 years (interquartile range (IQR) 2.6 to 7.8). Eight patients died and 35 THAs were revised. The use of metal-on-metal (MoM) bearings and resurfacing procedures declined after 2008. The most frequently recorded indications for revision were loosening (20%) and infection (20%), although the absolute risk of these events occurring was low (0.9%). Factors associated with lower implant survival were MoM and metal-on-polyethylene (MoP) bearings and resurfacing arthroplasty ( vs ceramic-on-polyethylene (CoP) and ceramic-on-ceramic (CoC) bearings, p = 0.002), and operations performed by surgeons who undertook few THAs in this age group as recorded in the NJR ( vs those with five or more recorded operations, p = 0.030). Kaplan–Meier estimates showed 96% (95% confidence interval (CI) 94% to 98%) survivorship of implants at five years.

Conclusion

Within the NJR, the overall survival for very young patients undergoing THA exceeded 96% during the first five postoperative years. In the absence of studies that can better account for differences in the characteristics of the patients, surgeons should consider the association between early revision and the type of implant, the number of THAs performed in these patients, and the bearing surface when performing THA in very young patients. Cite this article: Bone Joint J 2018;100-B:1320–9.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis

A systematic review was conducted on 30 December 2014 to determine whether prophylactic antibiotics reduce the risk of superficial infection and osteomyelitis following open distal phalanx fractures. Four randomized controlled trials (353 fractures) were suitable for meta-analysis. There was no statistically significant difference between rates of superficial infection in the two groups. This finding persisted when only the two most recent and highest quality trials were included. There were no reported cases of osteomyelitis in the pooled dataset, despite patients with 164 fractures not receiving antibiotics. These results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures. The focus of treatment should be on prompt irrigation and debridement rather than administration of prophylactic antibiotics.

Quality of care for patients with a fracture of the hip in major trauma centres

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.

Prophylactic antibiotics in elective hip and knee arthroplasty: an analysis of organisms reported to cause infections and National survey of clinical practice

Objectives

We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England.

Methods

Analysis of data routinely collected by Public Health England’s (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire.

Results

Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence.

Conclusions

The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies.

Cite this article: Bone Joint Res 2015;4:181–189.

Effect of regional trauma centralization on volume, injury severity and outcomes of injured patients admitted to trauma centres

BACKGROUND

Centralization of complex healthcare services into specialist high-volume centres is believed to improve outcomes. For injured patients, few studies have evaluated the centralization of major trauma services. The aim of this study was to evaluate how a regional trauma network affected trends in admissions, case mix, and outcomes of injured patients.

METHODS

A retrospective before-after study was undertaken of severely injured patients attending four hospitals that became major trauma centres (MTCs) in March 2012. Consecutive patients with major trauma were identified from a national registry and divided into two groups according to injury before or after the launch of a new trauma network. The two cohorts were compared for differences in case mix, demand on hospital resources, and outcomes.

RESULTS

Patient volume increased from 442 to 1326 (200 per cent), operations from 349 to 1231 (253 per cent), critical care bed-days from 1100 to 3704 (237 per cent), and total hospital bed-days from 7910 to 22,772 (188 per cent). Patient age increased on MTC designation from 45.0  years before March 2012 to 48.2 years afterwards (P = 0.021), as did the proportion of penetrating injuries (1.8 versus 4.1 per cent; P = 0.025). Injury severity fell as measured by median Injury Severity Score (16 versus 14) and Revised Trauma Score (4.1 versus 7.8). Fewer patients required secondary transfer to a MTC from peripheral hospitals (19.9 versus 16.1 per cent; P = 0.100). There were no significant differences in total duration of hospital stay, critical care requirements or mortality. However, there was a significant increase, from 55.5 to 62.3 per cent (P < 0.001), in the proportion of patients coded as having a 'good recovery' at discharge after institution of the trauma network.

CONCLUSION

MTC designation leads to an increased case volume with considerable implications for operating theatre capacity and bed occupancy. Although no mortality benefit was demonstrated within 6 months of establishing this trauma network, early detectable advantages included improved functional outcome at discharge.

Influence of patient age on drug costs: An investigation to validate the prescribing unit

The costs of 15,226 drug items prescribed by 22 doctors in two UK health centres were analysed with respect to patients' age and gender. For patients aged 65 and over, average drug costs per practice patient at the health centres were, respectively, 3.6 and 5.2 times greater, and the number of prescribed items 3.3 and 5.6 times greater, than for patients under 65. When analysed in 10 patient-age bands, there was a gradual increase in the number of prescribed items and average costs from the age of 35 to 74 years at each centre. Items and costs decreased for patients aged 75 and over. The increase in costs was the consequence of a general increase in prescribed items throughout the major therapeutic groups. The findings suggest that the prescribing unit, which is a weighting factor for age currently employed to standardise populations when making interpractice comparisons of prescribing costs, may not be wholly appropriate and could conceal important differences in some patient groups, especially the middle age ranges of 35 to 64 years.

Media coverage and public reaction to a celebrity cancer diagnosis

BACKGROUND

Celebrity diagnoses can have important effects on public behaviour. UK television celebrity Jade Goody died from cervical cancer in 2009. We investigated the impact of her illness on media coverage of cervical cancer prevention, health information seeking behaviour and cervical screening coverage.

METHODS

National UK newspaper articles containing the words 'Jade Goody' and 'cancer' were examined for public health messages. Google Insights for Search was used to quantify Internet searches as a measure of public health information seeking. Cervical screening coverage data were examined for temporal associations with this story.

RESULTS

Of 1203 articles, 116 (9.6%) included a clear public health message. The majority highlighted screening (8.2%). Fewer articles provided advice about vaccination (3.0%), number of sexual partners (1.4%), smoking (0.6%) and condom use (0.4%). Key events were associated with increased Internet searches for 'cervical cancer' and 'smear test', although only weakly with searches for 'HPV'. Cervical screening coverage increased during this period.

CONCLUSION

Increased public interest in disease prevention can follow a celebrity diagnosis. Although media coverage sometimes included public health information, articles typically focused on secondary instead of primary prevention. There is further potential to maximize the public health benefit of future celebrity diagnoses.

Intraspecific competition: the role of lags between attack and death in host-parasitoid interactions

Many natural enemies do not immediately kill their host, and the lag this creates between attack and host death results in mixed populations of uninfected and infected hosts. Both competition and parasitism are known to be major structuring forces in ecological communities; however, surprisingly little is known about how the competitive nature of infected hosts could affect the survival and dynamics of remaining uninfected host populations. Using a laboratory system comprising the Indian meal moth, Plodia interpunctella, and a solitary koinobiont parasitoid, Venturia canescens, we address this question by conducting replicated competition experiments between the unparasitized and parasitized classes of host larvae. For varying proportions of parasitized host larvae and competitor densities, we consider the effects of competition within (intraclass) and between (interclass) unparasitized and parasitized larvae on the survival, development time, and size of adult moths and parasitoid wasps. The greatest effects were on survival: increased competitor densities reduced survival of both parasitized and unparasitized larvae. However, unparasitized larvae survival, but not parasitized larvae survival, was reduced by increasing interclass competition. To our knowledge, this is the first experimental demonstration of the competitive superiority of parasitized over unparasitized hosts for limiting resources. We discuss possible mechanisms for this phenomenon, why it may have evolved, and its possible influence on the stability of host-parasite dynamics.

Diabetes mellitus and the rate of cognitive ageing

OBJECTIVES

There is some evidence that besides affecting peripheral neural function diabetes may also cause more widespread changes in the central nervous system which reduce cognitive efficiency and so, also, independence and quality of life. The present study explores whether diabetes mellitus is a compounding factor in average declines in cognitive performance observed in old age.

DESIGN

A sample of diabetics and controls were compared on a battery of cognitive tasks previously used in cognitive ageing research.

METHODS

Thirty-three insulin dependent (IDDM), 135 non-insulin dependent (NIDDM) diabetics and 2191 non-diabetics aged between 50 and 91 years were compared on two tests of general intellectual ability, and on three tests of verbal memory.

RESULTS

Overall, the combined IDDM and NIDDM groups had significantly lower average scores than the controls group on all cognitive tasks. Detailed analyses revealed most cognitive impairment for the NIDDM sub-group whose condition was managed by hypoglycaemic drugs, slightly less for those managed by diet, and no impairment for the IDDM group. These effects were independent of age, depression, socio-economic status, and presence of other illnesses.

CONCLUSIONS

Together with other recent studies these data emphasize the need for early detection and effective management of diabetes in older patients.

Mastocytosis: diverse presentations and outcomes

Within the general category of mastocytosis lies an array of clinical presentations with differing prognostic implications. We report 3 cases of systemic mastocytosis distinguished by novel aspects of the disease. Case 1 documents the first successful orthotopic liver transplantation in a patient with mastocytosis; case 2 depicts a potential hereditary component of mastocytosis; and case 3 documents the progression of mastocytosis with hematologic abnormality to mast cell leukemia. Future investigations, such as the early definition of c-kit receptor mutations, may provide additional insight as to the molecular basis for this heterogeneous disease and guidance for prognostic implications and targeted therapies.

The core content of the undergraduate curriculum in Manchester

AIM

To identify the core content for the new undergraduate medical curriculum in Manchester.

METHOD

The initial step was to produce a list of 'index clinical situations' (ICSs), for which a newly graduated doctor must have a required level of competence. Using repeated consultation with consultants and general practitioners involved in medical education in the North-West of England, a list of 215 ICSs was agreed. Specialists and generalists were then asked to identify the components of the knowledge base and the performance (skills) base for each ICS. The knowledge base was divided into technical (biomedical facts/concepts) and contextual (effect/management of disease within the individual, family and society) domains. The performance base was divided into intellectual (problem solving and decision making) and interpersonal (history, examination, communication and procedural skills) domains.

RESULTS

Forty specialties were consulted and 11,021 items (defined as a piece of knowledge, a concept or a skill) were identified. There was considerable overlap in the items listed, such that when the returns for each ICS were amalgamated, the 215 ICSs contained 6434 items with a mean of 34 +/- 14.2 per situation (range 6-85). UTILISATION: We have used the defined ICSs in the design of the trigger material used in the weekly problem-based learning sessions. Over 4 years almost all (207/215, 96%) of the ICS are covered, with many being revisited at several points in the curriculum.

Bone marrow-derived murine mast cells migrate, but do not degranulate, in response to chemokines

We have determined that several chemokines induce mast cell migration in vitro. This directed migration is dependent on the presence of particular extracellular matrix proteins and the activation status of the cells. Mast cell haptotactic responses were observed in response to various chemokines on vitronectin-, laminin-, and fibronectin-coated filters. Unstimulated mast cells were chemoattracted only by monocyte chemotactic protein-1 and RANTES on vitronectin-coated and, to a lesser extent, laminin-coated filters, whereas IgE-activated mast cells migrated in response to monocyte chemotactic protein-1, regulated on activation normal T expressed and secreted, platelet factor-4, and macrophage inflammatory protein-1 alpha on all three matrix proteins. No significant migration was observed on collagen type IV-coated or uncoated filters. Mast cell migration in response to chemokines on extracellular matrices and its enhancement by IgE-dependent activation provide a mechanism by which cells may be drawn to sites of inflammation. Chemokine-induced mast cell recruitment may be particularly relevant in host defense responses to parasitic infections, allergic reactions, Jones-Mote reactions, and in wound healing.

Bone marrow-derived murine mast cells migrate, but do not degranulate, in response to chemokines

We have determined that several chemokines induce mast cell migration in vitro. This directed migration is dependent on the presence of particular extracellular matrix proteins and the activation status of the cells. Mast cell haptotactic responses were observed in response to various chemokines on vitronectin-, laminin-, and fibronectin-coated filters. Unstimulated mast cells were chemoattracted only by monocyte chemotactic protein-1 and RANTES on vitronectin-coated and, to a lesser extent, laminin-coated filters, whereas IgE-activated mast cells migrated in response to monocyte chemotactic protein-1, regulated on activation normal T expressed and secreted, platelet factor-4, and macrophage inflammatory protein-1 alpha on all three matrix proteins. No significant migration was observed on collagen type IV-coated or uncoated filters. Mast cell migration in response to chemokines on extracellular matrices and its enhancement by IgE-dependent activation provide a mechanism by which cells may be drawn to sites of inflammation. Chemokine-induced mast cell recruitment may be particularly relevant in host defense responses to parasitic infections, allergic reactions, Jones-Mote reactions, and in wound healing.

GPs and managers. What the doctors saw

Low morale among many GPs was the trigger for a survey which examined the causes of communication breakdowns and misunderstandings. Mollie McBride and colleagues outline the results.

London after Tomlinson. Care in the capital: what needs to be done

One of the aims of the Tomlinson report is to shift more care from the secondary to the primary sector in London. But the primary sector is already underresourced and overloaded. The capital has a heterogeneous population which often makes inappropriate demands on general practitioners. Many premises are inadequate and there are insufficient support staff. David Metcalfe emphasises that London is special and that the shift will not become a reality unless these problems are tackled. He suggests the establishment of different models of practice centres which could treat some of the patients who now go to accident and emergency departments. Some would be the night emergency service base, some would have primary care beds, and each would have a different mix of specialist support.

The chains of education, experience, and culture

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Requirements for technology. As seen by providers of primary health care

This article is concerned with principles that might help to ensure that procedures and tools used in primary care are appropriate to people's needs and expectations. It urges attention, not first to technology, but to the broad range of purposes served by primary care and to the relevance of procedures to them. Other criteria for ensuring appropriateness are also proposed.

William Pickles lecture 1986. The crucible

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Clustering diagnoses: a method of interpreting morbidity data

Detailed classification of morbidity data provides problems in large-scale surveys in general practice: a balance between precise diagnosis and realistic uncertainty must be maintained, and it can be hard to detect the overall pattern when a large number of rubrics is involved. This paper reports the development of a system of clustered diagnoses in which similar diagnoses are linked together in homogeneous clusters. The system is based on the RCGP codes and is compatible with ICHPPC-2. The aim was not to produce another classification of morbidity but to use the system to apply to data already coded using a specific primary code.