Evaluation of the volume-value relationship in hip fracture care using evidence-based thresholds

Background: Studies have shown high-volume surgeons and hospitals deliver higher value care. The aims of this study were to establish meaningful thresholds defining high-volume surgeons and hospitals performing hip fracture surgery and to examine the relative market share of hip fracture cases using these surgeon and hospital strata. Methods: We performed a retrospective cohort study in a database of 103,935 patients undergoing hip fracture repair. We generated stratum-specific likelihood ratio (SSLR) models of a receiver operating characteristic (ROC) curve using length of stay (LOS) and cost value metrics. Volume thresholds predictive of decreased LOS and costs for surgeons and hospitals were identified. Results: Analysis of annual surgeon hip fracture volume produced two volume categories for LOS and cost: 0–30 (low) and 31+ (high). Analysis of LOS by annual hospital hip fracture volume produced strata at: 0–59 (low), 60–146 (medium), and 147 or more (high). Analysis of cost by annual hospital volume produced strata at: 0–125 (low) and 126+ (high). LOS and cost both decreased significantly ( p < 0.05) in progressively higher volume categories. Low-volume surgeons performed the majority of hip fracture cases, although they were performed at medium- or high-volume centres. Conclusions: This study demonstrates a direct relationship between volume and value, translating to improvement in hip fracture care delivery for both surgeons and hospitals. Higher volume hospitals while lower volume surgeons perform the majority of hip fracture cases, suggesting optimisation opportunities. However, systems-based practices at the hospital level likely drive value to a greater extent than individual surgeons.

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Hospital mortality after hip fracture surgery in relation to length of stay by care delivery factors

Medicine ◽

10.1097/md.0000000000006683 ◽

2017 ◽

Vol 96 (16) ◽

pp. e6683 ◽

Cited By ~ 9

Author(s):

Boris Sobolev ◽

Pierre Guy ◽

Katie J. Sheehan ◽

Eric Bohm ◽

Lauren Beaupre ◽

...

Keyword(s):

Hip Fracture ◽

Length Of Stay ◽

Hospital Mortality ◽

Care Delivery ◽

Hip Fracture Surgery ◽

Fracture Surgery

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Partial pressure of oxygen level at admission as a predictor of postoperative pneumonia after hip fracture surgery in a geriatric population: a retrospective cohort study

BMJ Open ◽

10.1136/bmjopen-2020-048272 ◽

2021 ◽

Vol 11 (10) ◽

pp. e048272

Author(s):

Yahong Ji ◽

Xiaoli Li ◽

Yakang Wang ◽

Li Cheng ◽

Hua Tian ◽

...

Keyword(s):

Risk Factors ◽

Hip Fracture ◽

Retrospective Cohort ◽

Operating Characteristic ◽

Validation Cohort ◽

Partial Pressure Of Oxygen ◽

Geriatric Population ◽

Training Cohort ◽

Hip Fracture Surgery ◽

Fracture Surgery

ObjectiveTo identify whether the partial pressure of oxygen in arterial blood (PaO2) level at admission is an independent risk factor as a prognostic biomarker to predict postoperative pneumonia (POP) in the geriatric population who have undergone hip fracture surgical repair at our hospital.DesignA retrospective cohort study.SettingThis is a retrospective chart review of POP after hip fracture surgery in China.ParticipantsIn training cohort, patients aged ≥65 years who had hip fracture surgery between 1 January 2018 and 30 November 2019. In the validation cohort, a series of patients who underwent hip fracture surgery between 1 January 2020 and 28 February 2020.InterventionsReceiver operating characteristic (ROC) analysis was used to obtain the area under the ROC curve (AUC) and cut-off values of PaO2 to predict POP. A binomial logistic regression model was used to identify potential risk factors for POP by analysing demographic distribution factors, laboratory results, preoperative comorbidities and surgical factors. Then the regression model was validated using an independent cohort.ResultsIn the training cohort, ROC curves were generated to compare the predictive performance of PaO2 for the occurrence of POP, and the area under the receiver operating characteristic curve (AUC) was 0.653 (95% CI 0.577 to 0.729, p<0.0001), with sensitivity and specificity values of 60.0% and 63.8%, respectively. The cut-off value of the PaO2 for POP was 72.5 mm Hg. Binary logistic regression analysis revealed that hypoxaemia (PaO2 <72.5 mm Hg) at hospital admission (OR=3.000, 95% CI 1.629 to 5.528; p<0.0001) was independent risk factors associated with POP after hip fracture surgery. In the validation cohort, PaO2 had a predictive eﬀect for POP (AUC 0.71, 95% CI 0.541 to 0.891).ConclusionsThe current study revealed that the PaO2 level at hospital admission is a simple and widely available biomarker predictor of POP after hip fracture surgery in elderly patients.

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Waiting time for hip fracture surgery: hospital variation, causes, and effects on postoperative mortality

Bone & Joint Open ◽

10.1302/2633-1462.29.bjo-2021-0079.r1 ◽

2021 ◽

Vol 2 (9) ◽

pp. 710-720

Author(s):

Cato Kjaervik ◽

Jan-Erik Gjertsen ◽

Lars B. Engeseter ◽

Eva Stensland ◽

Eva Dybvik ◽

...

Keyword(s):

Hip Fracture ◽

Waiting Time ◽

Waiting Times ◽

Working Hours ◽

High Volume ◽

Mortality Rates ◽

Hip Fracture Surgery ◽

Low Volume ◽

One Year ◽

Fracture Surgery

Aims This study aimed to describe preoperative waiting times for surgery in hip fracture patients in Norway, and analyze factors affecting waiting time and potential negative consequences of prolonged waiting time. Methods Overall, 37,708 hip fractures in the Norwegian Hip Fracture Register from January 2014 to December 2018 were linked with data in the Norwegian Patient Registry. Hospitals treating hip fractures were characterized according to their hip fracture care. Waiting time (hours from admission to start of surgery), surgery within regular working hours, and surgery on the day of or on the day after admission, i.e. ‘expedited surgery’ were estimated. Results Mean waiting time was 22.6 hours (SD 20.7); 36,652 patients (97.2%) waited less than three days (< 72 hours), and 27,527 of the patients (73%) were operated within regular working hours (08:00 to 16:00). Expedited surgery was given to 31,675 of patients (84%), and of these, 19,985 (53%) were treated during regular working hours. Patients classified as American Society of Anesthesiologists (ASA) classes 4 and 5 were more likely to have surgery within regular working hours (odds ratio (OR) 1.59; p < 0.001), and less likely to receive expedited surgery than ASA 1 patients (OR 0.29; p < 0.001). Low-volume hospitals treated a larger proportion of patients during regular working hours than high volume hospitals (OR 1.26; p < 0.001). High-volume hospitals had less expedited surgery and significantly longer waiting times than low and intermediate-low volume hospitals. Higher ASA classes and Charlson Comorbidity Index increased waiting time. Patients not receiving expedited surgery had higher 30-day and one-year mortality rates (OR 1.19; p < 0.001) and OR 1.13; p < 0.001), respectively. Conclusion There is inequality in waiting time for hip fracture treatment in Norway. Variations in waiting time from admission to hip fracture surgery depended on both patient and hospital factors. Not receiving expedited surgery was associated with increased 30-day and one-year mortality rates. Cite this article: Bone Jt Open 2021;2(9):710–720.

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Vitamin D deficiency is associated with reduced mobility after hip fracture surgery: a prospective study

American Journal of Clinical Nutrition ◽

10.1093/ajcn/nqaa029 ◽

2020 ◽

Vol 112 (3) ◽

pp. 613-618 ◽

Cited By ~ 2

Author(s):

Lihong Hao ◽

Jeffrey L Carson ◽

Yvette Schlussel ◽

Helaine Noveck ◽

Sue A Shapses

Keyword(s):

Vitamin D ◽

Hip Fracture ◽

Nutritional Status ◽

Vitamin D Deficiency ◽

Risk Index ◽

Fracture Repair ◽

Nutritional Risk ◽

Hip Fracture Surgery ◽

Nutritional Risk Index ◽

Fracture Surgery

ABSTRACT Background Hip fractures are associated with a high rate of morbidity and mortality, and successful ambulation after surgery is an important outcome in this patient population. Objective This study aims to determine whether 25-hydroxyvitamin D [25(OH)D] concentration or the Geriatric Nutritional Risk Index (GNRI) is associated with mortality or rates of walking in a patient cohort after hip fracture surgery. Methods Patients undergoing hip fracture repair from a multisite study in North America were included. Mortality and mobility were assessed at 30 and 60 d after surgery. Serum albumin, 25(OH)D, and intact parathyroid hormone were measured. Patients were characterized according to 25(OH)D <12 ng/mL, 12 to <20 ng/mL, 20 to <30 ng/mL, or ≥30 ng/mL. GNRI was categorized into major/moderate nutritional risk (<92), some risk (92 to <98), or in good nutritional status (≥98). Results Of the 290 patients [aged 82 ± 7 y, BMI (kg/m2): 25 ± 5], 73% were women. Compared with patients with <12 ng/mL, those with higher 25(OH)D concentrations had higher rates of walking at 30 d (P = 0.031): 12 to <20 ng/mL (adjusted OR: 2.61; 95% CI: 1.13, 5.99); 20 to <30 ng/mL (3.48; 1.53, 7.95); ≥30 ng/mL (2.84; 1.12, 7.20). In addition, there was also greater mobility at 60 d (P = 0.028) in patients with higher 25(OH)D compared with the reference group (<12 ng/mL). Poor nutritional status (GNRI <92) showed an overall trend to reduce mobility (unadjusted P = 0.044 and adjusted P = 0.056) at 30 but not at 60 d. There was no association of vitamin D or GNRI with mortality at either time. Conclusions Vitamin D deficiency (<12 ng/mL) is associated with reduced ambulation after hip fracture surgery, whereas GNRI also contributes to immobility but is a less reliable predictor. Mechanisms that can explain why vitamin D deficiency is associated with mobility should be addressed in future studies.

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High volumes of recent surgical admissions, time to surgery, and 60-day mortality

The Bone & Joint Journal ◽

10.1302/0301-620x.103b2.bjj-2020-1581.r1 ◽

2021 ◽

Vol 103-B (2) ◽

pp. 264-270

Author(s):

Sara Marie Nilsen ◽

Andreas Asheim ◽

Fredrik Carlsen ◽

Kjartan Sarheim Anthun ◽

Lars Gunnar Johnsen ◽

...

Keyword(s):

Hip Fracture ◽

High Volume ◽

Surgical Patients ◽

Hospital Capacity ◽

Delayed Surgery ◽

Time To Surgery ◽

Hip Fracture Surgery ◽

Mortality Hazard Ratio ◽

Fracture Surgery ◽

Surgical Admission

Aims Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. Methods This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. Results Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). Conclusion A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264–270.

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Variation in surgical demand and time to hip fracture repair: a Canadian database study

BMC Health Services Research ◽

10.1186/s12913-020-05791-5 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Katie J. Sheehan ◽

◽

Boris Sobolev ◽

Pierre Guy ◽

Jason D. Kim ◽

...

Keyword(s):

Hip Fracture ◽

Median Time ◽

Supply And Demand ◽

Fracture Repair ◽

Clearance Time ◽

Time To Surgery ◽

Hip Fracture Surgery ◽

Competing Demands ◽

Canadian Provinces ◽

Fracture Surgery

Abstract Background Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals. Methods We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay. Results For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1–6.1), 12.2% (95% CI 10.3–14.2), and 22.0% (95% CI 17.7–26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay. Conclusion Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

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The association between hospital case volume and in-hospital and one-year mortality after hip fracture surgery

The Bone & Joint Journal ◽

10.1302/0301-620x.102b10.bjj-2019-1728.r3 ◽

2020 ◽

Vol 102-B (10) ◽

pp. 1384-1391

Author(s):

Seokha Yoo ◽

Eun Jin Jang ◽

Junwoo Jo ◽

Jun Gi Jo ◽

Seungpyo Nam ◽

...

Keyword(s):

Hip Fracture ◽

Hospital Mortality ◽

High Volume ◽

Case Volume ◽

Hospital Case ◽

Hip Fracture Surgery ◽

Low Volume ◽

One Year ◽

Fracture Surgery ◽

Very High

Aims Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery. Methods Data for all patients who underwent surgery for hip fracture from January 2008 to December 2016 were extracted from the Korean National Healthcare Insurance Service database. According to mean annual case volume of surgery for hip fracture, hospitals were classified into very low (< 30 cases/year), low (30 to 50 cases/year), intermediate (50 to 100 cases/year), high (100 to 150 cases/year), or very high (> 150 cases/year) groups. The association between hospital case volume and in-hospital mortality or one-year mortality was assessed using the logistic regression model to adjust for age, sex, type of fracture, type of anaesthesia, transfusion, comorbidities, and year of surgery. Results Between January 2008 and December 2016, 269,535 patients underwent hip fracture surgery in 1,567 hospitals in Korea. Compared to hospitals with very high volume, in-hospital mortality rates were significantly higher in those with high volume (odds ratio (OR) 1.10, 95% confidence interval ((CI) 1.02 to 1.17, p = 0.011), low volume (OR 1.22, 95% CI 1.14 to 1.32, p < 0.001), and very low volume (OR 1.25, 95% CI 1.16 to 1.34, p < 0.001). Similarly, hospitals with lower case volume showed higher one-year mortality rates compared to hospitals with very high case volume (low volume group, OR 1.15, 95% CI 1.11 to 1.19, p < 0.001; very low volume group, OR 1.10, 95% CI 1.07 to 1.14, p < 0.001). Conclusion Higher hospital case volume of hip fracture surgery was associated with lower in-hospital mortality and one-year mortality in a dose-response fashion. Cite this article: Bone Joint J 2020;102-B(10):1384–1391.

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