Clinical outcomes of non-COVID-19 orthopaedic patients admitted during the COVID-19 pandemic: a multi-centre interrupted time series analysis across hospitals in six different countries

OBJECTIVES

To assess across seven hospitals from six different countries the extent to which the COVID-19 pandemic affected the volumes of orthopaedic hospital admissions and patient outcomes for non-COVID-19 patients admitted for orthopaedic care.

DESIGN

A multi-centre interrupted time series (ITS) analysis.

SETTING

Seven hospitals from six countries who collaborated within the Global Health Data@Work collaborative.

PARTICIPANTS

Non-COVID-19 patients admitted for orthopaedic care during the pre-pandemic (January/2018-February/2020) and COVID-19 pandemic (March/2020-June/2021) period. Admissions were categorised as: (1) acute admissions (lower limb fractures/neck of femur fractures/pathological fractures/joint dislocations/upper limb fractures); (2) subacute admissions (bone cancer); (3) elective admissions (osteoarthritis).

OUTCOME MEASURES

Monthly observed versus expected ratios (O/E) were calculated for in-hospital mortality, long (upper-decile) length-of-stay and hospital readmissions, with expected rates calculated based on case-mix. An ITS design was used to estimate the change in level and/or trend of the monthly O/E ratio by comparing the COVID-19 pandemic with the pre-pandemic period.

RESULTS

69 221 (pre-pandemic) and 22 940 (COVID-19 pandemic) non-COVID-19 orthopaedic patient admissions were included. Admission volumes were reduced during the COVID-19 pandemic for all admission categories (range: 33%-45%), with more complex patients treated as shown by higher percentages of patients admitted with ≥1 comorbidity (53.8% versus 49.8%, p<0.001). The COVID-19 pandemic was not associated with significant changes in patient outcomes for most diagnostic groups. Only for patients diagnosed with pathological fractures (pre-pandemic n=1671 and pandemic n=749), the COVID-19 pandemic was significantly associated with an immediate mortality reduction (level change of -77.7%, 95% CI -127.9% to -25.7%) and for lower limb fracture patients (pre-pandemic n=9898 and pandemic n=3307) with a significantly reduced trend in readmissions (trend change of -6.3% per month, 95% CI -11.0% to -1.6%).

CONCLUSIONS

Acute, subacute, as well as elective orthopaedic hospital admissions volumes were reduced in all global participating hospitals during the COVID-19 pandemic, while overall patient outcomes for most admitted non-COVID-19 patients remained the same despite the strain caused by the surge of COVID-19 patients.

Abstract W MP99: Seven-Day Mortality After Ischemic Stroke: International Comparison Among Industrialized Nations

Introduction: Stroke is the 2 nd leading cause of death worldwide, yet best practices for acute stroke care are lacking even among premier hospitals in industrialized countries. We compared 7-day mortality after ischemic stroke between academic medical centers in the Netherlands (NL), United Kingdom (UK), and United States (US).

Methods: This was an observational study using in-hospital administrative data from select academic medical centers in the NL (n=8), UK (n=10), and US (n=11) from 2005-12. Chi-square was used to compare 7-day in-hospital mortality between countries and across years, and to explore the effect of weekend admission. Multiple logistic regression was conducted to further examine factors associated with mortality, including sex, age, weekend admission, year, and country.

Results: From 2005-12, 51,409 patients were discharged with ischemic stroke from hospitals in the NL (n=6331), UK (n=25574), and US (n=19204). Mortality was significantly higher in the UK (8.1%) compared to the NL (6.4%) and US (4.8%) (p<0.0001). Moreover, mortality was higher in patients admitted on week-ends compared to weekdays in the UK (9.2% vs. 7.7%, p=0.0001), but not in the NL (6.8% vs. 6.3%, p=0.44) or US (4.8% vs. 4.9%, p=0.73). This “week-end effect” was consistent throughout all hospitals in the UK (p=0.0002) but much more variable in hospitals in the other two countries. In the UK, 7-day mortality improved with time, declining from 10.7% in 2006 to 6.3% in 2012 (p<0.0001). A decline in mortality was also seen in the NL (p=0.03), but remained unchanged in the US (p=0.72). The UK “weekend effect” also disappeared with time. Multiple logistic regression demonstrated that country and weekend admission remained a significant risk factor associated with mortality after controlling for age, gender, and year.

Conclusions: A comparison of 7-day mortality among academic medical centers in industrialized counties reveals stark variability. Although 2006 stroke mortality in UK hospitals was almost double that of US hospitals, dramatic reductions were subsequently seen. Further analysis of national policy or practice changes that have driven these improvements promise to be revealing.