scholarly journals Textbook process as a composite quality indicator for in-hospital hip fracture care

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Stijn C. Voeten ◽  
◽  
Michel W. J. M. Wouters ◽  
Franka S. Würdemann ◽  
Pieta Krijnen ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Hip Fracture ◽  
Hospital Stay ◽  
Quality Indicator ◽  
Hospital Level ◽  
Fracture Care ◽  
Process Indicator ◽  
Patient Level ◽  
Hospital Variation ◽  
Process Compliance

Abstract Summary Individual process indicators often do not enable the benchmarking of hospitals and often lack an association with outcomes of care. The composite hip fracture process indicator, textbook process, might be a tool to detect hospital variation and is associated with better outcomes during hospital stay. Purpose The aim of this study was to determine hospital variation in quality of hip fracture care using a composite process indicator (textbook process) and to evaluate at patient level whether fulfilment of the textbook process indicator was associated with better outcomes during hospital stay. Methods Hip fracture patients aged 70 and older operated in five hospitals between 1 January 2018 and 31 December 2018 were included. Textbook process for hip fracture care was defined as follows: (1) assessment of malnutrition (2) surgery within 24 h, (3) orthogeriatric management during admission and (4) operation by an orthopaedic trauma certified surgeon. Hospital variation analysis was done by computing an observed/expected ratio (O/E ratio) for textbook process at hospital level. The expected ratios were derived from a multivariable logistic regression analysis including all relevant case-mix variables. The association between textbook process compliance and in-hospital complications and prolonged hospital stay was determined at patient level in a multivariable logistic regression model, with correction for patient, treatment and hospital characteristics. In-hospital complications were anaemia, delirium, pneumonia, urinary tract infection, in-hospital fall, heart failure, renal insufficiency, pulmonary embolism, wound infection and pressure ulcer. Results Of the 1371 included patients, 753 (55%) received care according to textbook process. At hospital level, the textbook compliance rates ranged from 38 to 76%. At patient level, textbook process compliance was significantly associated with fewer complications (38% versus 46%) (OR 0.66, 95% CI 0.52–0.84), but not with hospital stay (median length of hospital stay was 5 days in both groups) (OR 1.01, 95% CI 0.78–1.30). Conclusion The textbook process indicator for hip fracture care might be a tool to detect hospital variation. At patient level, this quality indicator is associated with fewer complications during hospital stay.

scholarly journals Prior Admissions as a Risk Factor for Readmission in Patients Surgically Treated for Femur Fractures: Implications for a Potential Hip Fracture Bundle

2021 ◽  
Vol 12 ◽  
pp. 215145932199616
Author(s):  
Robert Erlichman ◽  
Nicholas Kolodychuk ◽  
Joseph N. Gabra ◽  
Harshitha Dudipala ◽  
Brook Maxhimer ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Hip Fracture ◽  
Logistic Regression Analysis ◽  
Hip Fractures ◽  
Surgical Procedure ◽  
Hospital Admissions ◽  
Fracture Care ◽  
Increased Risk ◽  
Payment Models

Introduction: Hip fractures are a significant economic burden to our healthcare system. As there have been efforts made to create an alternative payment model for hip fracture care, it will be imperative to risk-stratify reimbursement for these medically comorbid patients. We hypothesized that patients readmitted to the hospital within 90 days would be more likely to have a recent previous hospital admission, prior to their injury. Patients with a recent prior admission could therefore be considered higher risk for readmission and increased cost. Methods: A retrospective chart review identified 598 patients who underwent surgical fixation of a hip or femur fracture. Data on readmissions within 90 days of surgical procedure and previous admissions in the year prior to injury resulting in surgical procedure were collected. Logistic regression analysis was used to determine if recent prior admission had increased risk of 90-day readmission. A subgroup analysis of geriatric hip fractures and of readmitted patients were also performed. Results: Having a prior admission within one year was significantly associated (p < 0.0001) for 90-day readmission. Specifically, logistic regression analysis revealed that a prior admission was significantly associated with 90-day readmission with an odds ratio of 7.2 (95% CI: 4.8-10.9). Discussion: This patient population has a high rate of prior hospital admissions, and these prior admissions were predictive of 90-day readmission. Alternative payment models that include penalties for readmissions or fail to apply robust risk stratification may unjustly penalize hospital systems which care for more medically complex patients. Conclusions: Hip fracture patients with a recent prior admission to the hospital are at an increased risk for 90-day readmission. This information should be considered as alternative payment models are developed for hip fracture care.

scholarly journals Time-Driven Activity-Based Costing: A Better Way to Understand the Cost of Caring for Hip Fractures

2020 ◽  
Vol 11 ◽  
pp. 215145932095820
Author(s):  
Breanna L. Blaschke ◽  
Harsh R. Parikh ◽  
Sandy X. Vang ◽  
Brian P. Cunningham
Keyword(s):  
Hip Fracture ◽  
Hip Fractures ◽  
Financial Strain ◽  
Process Mapping ◽  
Activity Based Costing ◽  
Fracture Care ◽  
Patient Level ◽  
Reducing Costs ◽  
The Cost ◽  
Payment Models

Geriatric hip fractures are a common and costly injury. They are expected to surge in incidence and economic burden as the population ages. With an increasing financial strain on the healthcare system, payors and providers are looking toward alternative, value-based models to contain costs. Value in healthcare is the ratio of outcomes achieved over costs incurred, and can be improved by reducing cost while maintaining or improving outcomes, or by improving outcomes while maintaining or reducing costs. Therefore, an understanding of cost, the denominator of the value equation, is essential to value-based healthcare. Because traditional hospital accounting methods do not link costs to conditions, there has been little research to date on the costs of treating geriatric hip fractures over the entire cycle of care. The aim of this article is to summarize existing costing methodologies, and in particular, to review the strengths and limitations of Time-Driven Activity-Based Costing (TDABC) in orthopaedic trauma, especially as it pertains to the needs and challenges unique to hip fracture care. TDABC determines costs at the patient-level over the entire care cycle, allowing for population variability, while simultaneously identifying cost drivers that might inform risk-stratification for future alternative payment models. Through process mapping, TDABC also reveals areas of variation or inefficiency that can be targeted for optimization, and empowers physicians by focusing on costs in the control of the provider. Although barriers remain, TDABC is well-positioned to provide transparent costing and targets to improve the value of hip fracture care

scholarly journals COVID-19 pandemic and hip fractures: impact and lessons learned

2020 ◽  
Vol 1 (9) ◽  
pp. 530-540
Author(s):  
Mohamed Arafa ◽  
Samia Nesar ◽  
Hamza Abu-Jabeh ◽  
Ma Odette Remelou Jayme ◽  
Yegappan Kalairajah
Keyword(s):  
Hip Fracture ◽  
Hospital Stay ◽  
Hip Fractures ◽  
Care Service ◽  
Health Concern ◽  
Positive Group ◽  
Fracture Care ◽  
Significant Difference ◽  
The Uk ◽  
The Impact

Aims The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks. Methods Data were collected retrospectively on 157 hip fractures admitted from March to May 2019 and 2020. The 2020 group was further subdivided into COVID-positive and COVID-negative. Data including the four-hour target, timing to imaging, hours to operation, anaesthetic and operative details, intraoperative complications, postoperative reviews, COVID status, Key Performance Indicators (KPIs), length of stay, postoperative complications, and the 30-day mortality were compiled from computer records and our local National Hip Fracture Database (NHFD) export data. Results Hip fractures and inpatient falls significantly increased by 61.7% and 7.2% respectively in the 2020 group. A significant difference was found among the three groups regarding anaesthetic preparation time, anaesthetic time, and recovery time. The mortality rate in the 2020 COVID-positive group (36.8%) was significantly higher than both the 2020 COVID-negative and 2019 groups (11.5% and 11.7% respectively). The hospital stay was significantly higher in the COVID-positive group (mean of 24.21 days (SD 19.29)). Conclusion COVID-19 has had notable effects on the hip fracture care service: hip fracture rates increased significantly. There were inefficiencies in theatre processes for which we have recommended the use of alternate theatres. COVID-19 infection increased the 30-day mortality and hospital stay in hip fractures. More research needs to be done to reduce this risk. Cite this article: Bone Joint Open 2020;1-9:530–540.

scholarly journals Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery

2018 ◽  
Vol 129 (6) ◽  
pp. 1121-1131 ◽  
Author(s):  
Daniel I. McIsaac ◽  
Duminda N. Wijeysundera ◽  
Gregory L. Bryson ◽  
Allen Huang ◽  
Colin J. L. McCartney ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Odds Ratio ◽  
Antiplatelet Agents ◽  
Neuraxial Anesthesia ◽  
Hospital Level ◽  
Patient Factors ◽  
Cross Sectional ◽  
Hip Fracture Surgery ◽  
Patient Level ◽  
Fracture Surgery

Abstract Editor’s Perspective What We Already Know about This Topic What This Manuscript Tells Us That Is New Background Substantial variation in primary anesthesia type for hip fracture surgery exists. Previous work has demonstrated that patients cared for at hospitals using less than 20 to 25% neuraxial anesthesia have decreased survival. Therefore, the authors aimed to identify sources of variation in anesthesia type, considering patient-, anesthesiologist-, and hospital-level variables. Methods Following protocol registration (NCT02787031), the authors conducted a cross-sectional analysis of a population-based cohort using linked administrative data in Ontario, Canada. The authors identified all people greater than 65 yr of age who had emergency hip fracture surgery from April 2002 to March 2014. Generalized linear mixed models were used to account for hierarchal data and measure the adjusted association of hospital-, anesthesiologist-, and patient-level factors with neuraxial anesthesia use. The proportion of variation attributable to each level was estimated using variance partition coefficients and the median odds ratio for receipt of neuraxial anesthesia. Results Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic. The median odds ratio for receiving neuraxial anesthesia was 2.36 between randomly selected hospitals and 2.36 between randomly selected anesthesiologists. The majority (60.1%) of variation in neuraxial anesthesia use was explained by patient factors; 19.9% was attributable to the anesthesiologist providing care and 20.0% to the hospital where surgery occurred. The strongest patient-level predictors were absence of preoperative anticoagulant or antiplatelet agents, absence of obesity, and presence of pulmonary disease. Conclusions While patient factors explain most of the variation in neuraxial anesthesia use for hip fracture surgery, 40% of variation is attributable to anesthesiologist and hospital-level practice. Efforts to change practice patterns will need to consider hospital-level processes and anesthesiologists’ intentions and behaviors.

Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes

2018 ◽  
Vol 128 (3) ◽  
pp. 480-491 ◽  
Author(s):  
Daniel I. McIsaac ◽  
Duminda N. Wijeysundera ◽  
Allen Huang ◽  
Gregory L. Bryson ◽  
Carl van Walraven
Keyword(s):  
Hip Fracture ◽  
Population Based ◽  
Neuraxial Anesthesia ◽  
Sensitivity Analyses ◽  
Causal Mechanism ◽  
Hospital Level ◽  
Hip Fracture Surgery ◽  
Patient Level ◽  
A Prospective Study ◽  
Fracture Surgery

Abstract Background There is consistent and significant variation in neuraxial anesthesia use for hip fracture surgery across jurisdictions. We measured the association of hospital-level utilization of neuraxial anesthesia, independent of patient-level use, with 30-day survival (primary outcome) and length of stay and costs (secondary outcomes). Methods We conducted a population-based cohort study using linked administrative data in Ontario, Canada. We identified all hip fracture patients more than 65 yr of age from 2002 to 2014. For each patient, we measured the proportion of hip fracture patients at their hospital who received neuraxial anesthesia in the year before their surgery. Multilevel, multivariable regression was used to measure the association of log-transformed hospital-level neuraxial anesthetic-use proportion with outcomes, controlling for patient-level anesthesia type and confounders. Results Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic; utilization varied from 0 to 100% between hospitals. In total, 9,122 (8.5%) of patients died within 30 days of surgery. Survival independently improved as hospital-level neuraxial use increased (P = 0.009). Primary and sensitivity analyses demonstrated that most of the survival benefit was realized with increase in hospital-level neuraxial use above 20 to 25%; there did not appear to be a substantial increase in survival above this point. No significant associations between hospital neuraxial anesthesia-use and other outcomes existed. Conclusions Hip fracture surgery patients at hospitals that use more than 20 to 25% neuraxial anesthesia have improved survival independent of patient-level anesthesia type and other confounders. The underlying causal mechanism for this association requires a prospective study to guide improvements in perioperative care and outcomes of hip fracture patients.

Abstract 183: Association of Hospital-Level Factors With Variation in Survival After Out-Of-Hospital Cardiac Arrest Between Receiving Hospitals in Japan

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Satoshi Koyama ◽  
Koichiro Gibo ◽  
Yutaka Yamaguchi ◽  
Masashi Okubo
Keyword(s):  
Cardiac Arrest ◽  
Patient Outcomes ◽  
Cerebral Performance Category ◽  
Temperature Management ◽  
Secondary Outcome ◽  
Hospital Level ◽  
Extracorporeal Cardiopulmonary Resuscitation ◽  
Patient Level ◽  
Hospital Variation ◽  
Hospital Cardiac Arrest

Background: Patient outcomes after out-of-hospital cardiac arrest (OHCA) varies at multiple levels (geographic regions, emergency medical service agencies, and receiving hospitals). However, the contribution of hospital-level factors to the outcome variation is unclear. We aimed to investigate the association between hospital-level factors and variation in outcomes after OHCA between hospitals. Methods: We performed secondary analysis of the Japanese Association for Acute Medicine OHCA Registry, a prospective multi-center registry. We included adults (≥18 years) with OHCA of medical origin between June 2014 and December 2015. The primary outcome was 1-month survival and secondary outcome was 1-month survival with favorable functional status, defined as Cerebral Performance Category scale 1 or 2. We constructed two multivariable hierarchical logistic regression models for each outcome: (1) patient-level factors and (2) patient- and hospital-level factors. Hospital-level factors included the number of medical staff involved in resuscitation, proportion of patients who received targeted temperature management among those with return of spontaneous circulation, and proportion of patients who received extracorporeal cardiopulmonary resuscitation among those with shockable rhythm. We calculated adjusted outcomes for each hospital and median odds ratios (MORs) to evaluate the effects of hospital-level factors on between-hospital variation in outcomes. Results: We analyzed the data of 9,303 adults with OHCA of medical origin treated at 67 hospitals. After adjustment for patient-level factors, 1-month survival was 0.02-0.14 (adjusted MOR, 1.36; 95% credible interval (CI), 1.17-1.77). After adjustment for patient- and hospital-level factors, the adjusted MOR was 1.14 (95% CI, 1.05-1.33). Similarly, the adjusted MORs for favorable functional outcomes were 1.48 (95% CI 1.18-2.12) with adjustment for patient-level factors and 1.30 (95% CI 1.07-1.80) with adjustment for patient- and hospital-level factors. Conclusions: With adjustment for hospital-level factors, we noted attenuation of variation in patient outcomes after OHCA across hospitals, suggesting that hospital-level factors may partly explain outcome variations.

Predictors of Length of Hospital Stay in Elderly Hip Fracture Patients

2013 ◽  
Vol 22 (02) ◽  
pp. 160-163 ◽  
Author(s):  
Christopher A. Brown ◽  
Steven Olson ◽  
Robert Zura
Keyword(s):  
Hip Fracture ◽  
Hospital Stay ◽  
Length Of Hospital Stay

scholarly journals Impact of Rehabilitation Dose on Nutritional Status at Discharge from a Convalescent Rehabilitation Ward in Malnourished Patients with Hip Fracture

Healthcare ◽  
2021 ◽  
Vol 9 (6) ◽  
pp. 722
Author(s):  
Yusuke Ito ◽  
Hidetaka Wakabayashi ◽  
Shinta Nishioka ◽  
Shin Nomura ◽  
Ryo Momosaki
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Hip Fracture ◽  
Nutritional Status ◽  
Logistic Regression Analysis ◽  
Short Form ◽  
Mini Nutritional Assessment ◽  
Functional Independence ◽  
Rehabilitation Ward ◽  
The Impact

The object of this study is to determine the impact of the rehabilitation dose on the nutritional status at discharge from a convalescent rehabilitation ward in malnourished patients with hip fracture. This retrospective case-control study involved malnourished patients with hip fracture aged 65 years or older who had been admitted to a convalescent rehabilitation ward and whose data were registered in the Japan Rehabilitation Nutrition Database. The primary outcome was nutritional status at discharge. Patients were classified according to whether nutritional status was improved or not at discharge, according to the Mini Nutritional Assessment-Short Form® (MNA-SF) score. The association between improved nutritional status and rehabilitation dose was assessed by a logistic regression analysis. Data were available for 145 patients (27 men, 118 women; mean age 85.1 ± 7.9 years). Daily rehabilitation dose was 109.5 (median 94.6–116.2) min and the MNA-SF score at admission was 5 (median 4–6). Nutritional status was improved in 97 patients and not improved in 48. Logistic regression analysis showed the following factors to be independently associated with nutritional status at discharge: Functional Independence Measure score (OR 1.042, 95% CI 1.016–1.068), energy intake (OR 1.002 CI 1.000–1.004), daily rehabilitation dose (OR 1.023, 95% CI 1.002–1.045), and length of hospital stay (OR 1.026, 95% CI 1.003–1.049). The daily rehabilitation dose in malnourished patients with hip fracture may positively impact nutritional status at discharge.

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