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Nishimura H, Suzuki H, Tokutsu K, Muramatsu K, Kawasaki M, Yamanaka Y, Uchida S, Nakamura E, Fushimi K, Matsuda S, Sakai A. Early surgical treatment using regional clinical pathways to reduce the length of postoperative hospital stay in hip fracture patients: A retrospective analysis using the Japanese Diagnosis Procedure Combination database. PLoS One 2024; 19:e0282766. [PMID: 39083486 PMCID: PMC11290638 DOI: 10.1371/journal.pone.0282766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/04/2024] [Indexed: 08/02/2024] Open
Abstract
Hip fracture is a common injury in older adults; however, the optimal timing of surgical treatment remains undetermined in Japan. Therefore, this retrospective study aimed to ascertain the rate of early surgery among hip fracture patients and investigate its effectiveness, along with "regional clinical pathways" (patient plan of care devised by Japanese clinicians), in reducing the length of hospital stay (LOS) postoperatively. We hypothesized that performing early surgery along with a regional clinical pathway is effective to reduce the postoperative LOS and complications among hip fracture patients. We examined the data of patients diagnosed with femoral neck and peritrochanteric fractures retrieved from the Japanese Diagnosis Procedure Combination database between April 2016 and March 2018. Patients were divided into the early (43,928, 34%; surgery within 2 days of admission) and delayed (84,237, 66%; surgery after 2 days of admission) surgery groups. The difference in postoperative LOS between the two groups was 3 days (early vs. delayed: 29 days vs. 32 days). The early surgery group had more cases of intertrochanteric fractures (57% vs. 43%) and internal fixation (74% vs. 55%) than did the delayed surgery group. In contrast, the delayed surgery group had more cases of femoral neck fractures (43% vs. 57%) and bipolar hip arthroplasty (25% vs. 42%) or total hip arthroplasty (1.2% vs. 3.0%). Moreover, the early surgery group showed a lower incidence of complications, except anemia (12% vs. 8.8%). Logistic regression analysis using the adjusted model revealed that early surgery and implementation of regional clinical pathways reduced LOS by 2.58 and 8.06 days, respectively (p<0.001). Early surgery and implementation of regional clinical pathways for hip fracture patients are effective in reducing postoperative LOS, allowing regional clinical pathways to have a greater impact. These findings will help acute care providers when treating hip fracture patients.
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Affiliation(s)
- Haruki Nishimura
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hitoshi Suzuki
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kei Tokutsu
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Keiji Muramatsu
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Makoto Kawasaki
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiaki Yamanaka
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Soshi Uchida
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Eiichiro Nakamura
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Shinya Matsuda
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Akinori Sakai
- Department of Orthopaedics Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Gadgaard NR, Varnum C, Nelissen RGHH, Vandenbroucke-Grauls C, Sørensen HT, Pedersen AB. Comorbidity and risk of infection among patients with hip fracture: a Danish population-based cohort study. Osteoporos Int 2023; 34:1739-1749. [PMID: 37330437 PMCID: PMC10511604 DOI: 10.1007/s00198-023-06823-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/06/2023] [Indexed: 06/19/2023]
Abstract
Impact of comorbidity on infection risk among hip fracture patients is unclear. We found high incidence of infection. Comorbidity was an important risk factor for infection up to 1 year after surgery. Results indicates a need for additional investment in pre- and postoperative programs that assist patients with high comorbidity. PURPOSE Comorbidity level and incidence of infection have increased among older patients with hip fracture. The impact of comorbidity on infection risk is unclear. We conducted a cohort study examining the absolute and relative risks of infection in relation to comorbidity level among hip fracture patients. METHODS Utilizing Danish population-based medical registries, we identified 92,600 patients aged ≥ 65 years undergoing hip fracture surgery between 2004 and 2018. Comorbidity was categorized by Charlson comorbidity index scores (CCI): none (CCI = 0), moderate (CCI = 1-2), or severe (CCI ≥ 3). Primary outcome was any hospital-treated infection. Secondary outcomes were hospital-treated pneumonia, urinary tract infection, sepsis, reoperation due to surgical-site infection (SSI), and a composite of any hospital- or community-treated infection. We calculated cumulative incidence and hazard ratios (aHRs) adjusted for age, sex, and surgery year, including 95% confidence intervals (CIs). RESULTS Prevalence of moderate and severe comorbidity was 40% and 19%, respectively. Incidence of any hospital-treated infection increased with comorbidity level within 0-30 days (none 13% vs. severe 20%) and 0-365 days (none 22% vs. 37% severe). Patients with moderate and severe comorbidity, compared to no comorbidity, had aHRs of 1.3 (CI: 1.3-1.4) and 1.6 (CI: 1.5-1.7) within 0-30 days, and 1.4 (CI: 1.4-1.5) and 1.9 (CI: 1.9-2.0) within 0-365, respectively. Highest incidence was observed for any hospital- or community-treated infection (severe 72%) within 0-365 days. Highest aHR was observed for sepsis within 0-365 days (severe vs. none: 2.7 (CI: 2.4-2.9)). CONCLUSION Comorbidity is an important risk factor for infection up to 1 year after hip fracture surgery.
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Affiliation(s)
- N R Gadgaard
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark.
| | - C Varnum
- Department of Orthopedic Surgery, Lillebaelt Hospital, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - R G H H Nelissen
- Department of Orthopedics, Leiden University Medical Center, Leiden, The Netherlands
| | - C Vandenbroucke-Grauls
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - H T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark
| | - A B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark
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Schlauch AM, Shah I, Caicedo M, Raji OR, Farrell B. Missing the first post-operative visit is an independent risk factor for 90-day complication and re-admission following hip fracture surgery. J Orthop 2023; 36:7-10. [PMID: 36578975 PMCID: PMC9791690 DOI: 10.1016/j.jor.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Introduction Knowing the risk factors for poor outcomes following hip fracture surgery is necessary for appropriate patient care. The objective of this study was to determine if the first post-operative visit (POV) following hip fracture surgery is a risk factor for increased mortality, complications, and re-admissions. Methods This was a retrospective review of 285 patients who underwent operative fixation of a hip fracture at an academic acute care hospital. Outcome measurements were 90-day and one year mortality, 90-day complications, and 90-day re-admission rates in patients who missed or attended their first post-operative visit following hip fracture surgery. Results 279 patients met inclusion criteria and had sufficient data for analysis, of which 213 (76.3%) made their first post-operative visit. 90-day and one-year mortality were significantly higher in the patients who missed their first POV (31.8% vs. 4.2%; 51.5% vs. 12.7%). Independent risk factors for 90-day complications were missing the first POV, coronary artery disease, and lower pre-injury status (ORs = 10.65, 2.80, 7.89, respectively). Independent risk factors for 90-day re-admission were missing the first POV, chronic obstructive pulmonary disease on home oxygen, and lower re-injury status (ORs = 8.04, 5.44, 5.47, respectively). Conclusion Missing the first POV was the strongest independent risk factor for 90-day complications and 90-day readmission. Patients who miss their first POV have significantly higher 90-day and one year mortality rates.
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Affiliation(s)
- Adam Michael Schlauch
- San Francisco Orthopaedic Residency Program, 450 Stanyan Street, San Francisco, CA, 94117, USA
| | - Ishan Shah
- San Francisco Orthopaedic Residency Program, 450 Stanyan Street, San Francisco, CA, 94117, USA
| | - Maria Caicedo
- The Taylor Collaboration, 2255 Hayes St, San Francisco, CA, 94117, USA
| | | | - Brian Farrell
- Kaiser Permanente, 3600 Broadway, Oakland, CA, 94611, USA
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Connelly DM. Recovery in Mobility by Community-Living Older Adults following Fragility Hip Fracture. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2022. [DOI: 10.1080/02703181.2021.2008086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Denise M. Connelly
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario London Ontario, Canada
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Ek S, Meyer AC, Hedström M, Modig K. Hospital length of stay after hip fracture and its association with 4-month mortality - Exploring the role of patient characteristics. J Gerontol A Biol Sci Med Sci 2021; 77:1472-1477. [PMID: 34622920 PMCID: PMC9255691 DOI: 10.1093/gerona/glab302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 11/22/2022] Open
Abstract
Background Hospital length of stay (LoS) is believed to be associated with higher mortality in hip fracture patients; however, previous research has shown conflicting results. We aimed to explore the association between LoS and 4-month mortality in different groups of hip fracture patients. Methods The study population in this Swedish register-based cohort study was 47 811 patients 65 years or older with a first hip fracture during 2012–2016, followed up for 4 months after discharge. LoS was categorized by cubic splines, and the association between LoS and mortality was analyzed with Cox regression models, adjusted for sociodemographic- and health-related factors. Results Mean LoS was 11.2 ± 5.9 days and 12.3% of the patients died within 4 months. Both a shorter and a longer LoS, compared to the reference 9–12 days, were associated with higher mortality (hazard ratio [95% confidence interval]): 2–4 days 2.15 (1.98–2.34), 5–8 days 1.58 (1.47–1.69), and 24+ days 1.29 (1.13–1.46). However, in fully adjusted models, only the association with a long LoS remained: 13–23 days 1.08 (1.00–1.17) and 24+ days 1.42 (1.25–1.61). Stratifying by living arrangement revealed that the increased risk for a short LoS was driven by the group living in care homes. For patients living at home, a short LoS was associated with lower risk: 0.65 (0.47–0.91) and 0.85 (0.74–0.98) for 2–4 and 5–8 days, respectively. Conclusions A long LoS after a hip fracture is associated with increased 4-month mortality risk even after considering patient characteristics. The association between mortality and a short LoS, however, is explained by individuals coming from care homes (with higher mortality risk), being discharged early.
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Affiliation(s)
- Stina Ek
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna C Meyer
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Margareta Hedström
- Department of Orthopedics, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Jiang Y, Luo Y, Lyu H, Li Y, Gao Y, Fu X, Wu H, Wu R, Yin P, Zhang L, Tang P. Trends in Comorbidities and Postoperative Complications of Geriatric Hip Fracture Patients from 2000 to 2019: Results from a Hip Fracture Cohort in a Tertiary Hospital. Orthop Surg 2021; 13:1890-1898. [PMID: 34431625 PMCID: PMC8523760 DOI: 10.1111/os.13142] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/30/2021] [Accepted: 08/02/2021] [Indexed: 01/14/2023] Open
Abstract
Objective To describe the secular trends in comorbidities and postoperative complications of geriatric hip fracture patients from the Chinese People's Liberation Army General Hospital Hip Fracture Cohort between 2000 and 2019. Methods We included 2,805 hip fracture patients aged 65 years or older and received surgical treatment from 25 January 2000 to 19 December 2019. Demographic characteristics, comorbidities, postoperative complications, length of hospital stay, and the time to surgery were extracted and examined in each 5‐year period based on the admission year, namely 2000–2004, 2005–2009, 2010–2014, and 2015–2019. Categorical data were analyzed by chi‐squared or Fisher's exact test, with ordinal data by row mean scores difference test and continuous data by one‐way analysis of variance. Trends in comorbidities and postoperative complications were examined by the Cochran–Armitage trend test. Results The average age of the included population was 79.1 ± 7.3 years (mean ± standard deviation), and 69.1% were female. From 2000 to 2019, the proportion of females increased from 59.8% to 73.0% (P for trend <0.05). Hypertension (51.8%), type 2 diabetes (23.6%), coronary heart disease (20.9%), stroke (18.7%), and arrhythmia (11.2%) were the most prevalent five comorbidities. The proportion of hypertension was 27.0%, 45.4%, 53.0%, and 57.2% in each 5‐year period with an increasing trend (P for trend <0.05). The proportion of type 2 diabetes was 9.8%, 22.8%, 23.5%, and 26.0% in each 5‐year period (P for trend <0.05). Similar increasing trends were found in myocardial infarction, arrhythmia, and tumor. On the contrary, the proportion of patients with major postoperative complications decreased from 2000 to 2019, with 23.0%, 14.6%, 6.5%, and 5.6% in each 5‐year period (P for trend <0.05). For each specific postoperative complication, i.e. pneumonia, cardiovascular event, respiratory failure, and in‐hospital death, similar decreasing trends were found (all P for trend <0.05). Conclusion This descriptive analysis sheds light on the fact that the health status of the hip fracture population tends to shift gradually. Improving concepts and practices of clinical interventions may help reduce postoperative complications, whereas challenges in the management of comorbidities increase.
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Affiliation(s)
- Yu Jiang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Yan Luo
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Houchen Lyu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Yi Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Yuan Gao
- Nursing Department, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaojie Fu
- Nursing Department, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huan Wu
- Research of Medical Big Data Center, Chinese PLA General Hospital, Beijing, China
| | - Rilige Wu
- Research of Medical Big Data Center, Chinese PLA General Hospital, Beijing, China
| | - Pengbin Yin
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Licheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
| | - Peifu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing, China
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Schoeneberg C, Aigner R, Pass B, Volland R, Eschbach D, Peiris SE, Ruchholtz S, Lendemans S. Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: A retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®. Injury 2021; 52:554-561. [PMID: 32951920 DOI: 10.1016/j.injury.2020.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Time-to-surgery in geriatric hip fractures remains of interest. The majority of the literature reports a significantly decreased mortality rate after early surgery. Nevertheless, there are some studies presenting no effect of time-to-surgery on mortality. The body of literature addressing the effect of an orthogeriatric co-management is growing. Here we investigate the effect of time-to-surgery on in-house mortality in a group of patients treated under the best possible conditions in certified orthogeriatric treatment units. METHODS We conducted a retrospective cohort registry analysis from prospectively collected data of the AltersTraumaRegister DGU®. Data were analyzed univariably, and the association of early surgery with in-house mortality was assessed with multivariable logistic regression while controlling for specified patient characteristics. Additionally, propensity score matching for time-to-surgery was applied to examine its effect on the in-house mortality rate. FINDINGS A total of 15,099 patients met the inclusion criteria. The median age was 85 years (IQR 80-89), and 72.1% were female. The overall in-house mortality rate was 5.5%. Most (71.2%) of the patients were treated within 24 h, and 91.6% within 48 h. Neither the multivariable logistic regression model nor the propensity score matching indicated that early surgery was associated with a decreased mortality rate. The most important indicators for mortality were ASA ≥ 3 [Odds ratio (OR) 3.4, 95% confidence interval (CI) 2.35-5.11], fracture event during inpatient stay (OR 2.6, 95% CI 1.48-4.3), ISAR ≥ 2 (OR 1.88, 95% CI 1.33-2.76), and male gender (OR 1.71, 95% CI 1.39-2.09). INTERPRETATION Our results suggest that for those patients, who were treated in an orthogeriatric co-management under the best possible conditions, there are no significant differences regarding in-house mortality rate between the time-to-surgery intervals of 24 and 48 h or slightly above. This and the comparatively small number of patients who underwent surgery after 24 h show that an extension of the pre-surgery interval, justified by an orthogeriatric treatment team, will not be detrimental to the affected patients.
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Affiliation(s)
- Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
| | - Rene Aigner
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | - Bastian Pass
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
| | - Ruth Volland
- AUC, Akademie der Unfallchirurgie GmbH, Munich, Germany.
| | - Daphne Eschbach
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | | | - Steffen Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | - Sven Lendemans
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany.
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- Working Committee on Geriatric Trauma Registry (AK ATR) of the German Trauma Society (DGU), Berlin, Germany
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Vasconcelos PABD, Rocha ADJ, Fonseca RJDS, Teixeira TRG, Mattos EDSR, Guedes A. Femoral fractures in the elderly in Brasil - incidence, lethality, and costs (2008-2018). Rev Assoc Med Bras (1992) 2020; 66:1702-1706. [PMID: 33331580 DOI: 10.1590/1806-9282.66.12.1702] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/27/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To describe the incidence by gender and region, lethality, and costs associated with the treatment of femoral fractures in the elderly (≥ 60 years) hospitalized in the Unified Health System (SUS) of Brasil between 2008 and 2018. METHODS This is a cross-sectional, descriptive, retrospective study of hospitalizations of elderly people due to femoral fractures by analyzing secondary data obtained from the SUS Hospital Information System (SIH/SUS) between 2008 and 2018; for calculation of epidemiological coefficients, we used information from demographic censuses (2000 and 2010) of the Brazilian Geography and Statistics Institute (IBGE). RESULTS A total of 478,274 hospitalizations were recorded in the period; the incidence was 1.7 times higher in females (overall average of 274.91/100,000 for women and 161/100,000 for men). The Southeast region had the highest absolute number of hospitalizations and the South region presented the highest annual overall average incidence (224.02/100,000). The average annual cost for SUS for the treatment of femoral fractures in the elderly was R$ 99,718,574.30. CONCLUSIONS In the evaluated period (2008-2018), femoral fractures in the elderly had a high incidence (478,274 hospitalizations; 224.02 cases/100,000 elderly), a predominance of females (1.7F/1.0M), a higher absolute number of hospitalizations in the Southeast region and a higher incidence in the South region; the lethality was high (an increase of 17.46%; overall mean coefficient of 4.99%/year); and the costs for the SUS were huge (an increase of 126.24%; average annual expenditure of R$ 99,718,574.30).
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Affiliation(s)
- Paula Antas Barbosa de Vasconcelos
- Residente, Programa de Residência Médica em Ortopedia e Traumatologia do Complexo Hospitalar Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Anderson de Jesus Rocha
- Residente, Programa de Residência Médica em Ortopedia e Traumatologia do Complexo Hospitalar Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Rodrigo Jorge de Souza Fonseca
- Residente, Programa de Residência Médica em Ortopedia e Traumatologia do Complexo Hospitalar Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | | | - Enilton de Santana Ribeiro Mattos
- Preceptor, PRM em Ortopedia e Traumatologia do Complexo Hospitalar Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Alex Guedes
- Professor Associado-Doutor, Chefe da Disciplina Cirurgia do Aparelho Locomotor, Departamento de Cirurgia Experimental e Especialidades Cirúrgicas, Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, BA, Brasil
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9
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Sheehan KJ, Guerrero EM, Tainter D, Dial B, Milton-Cole R, Blair JA, Alexander J, Swamy P, Kuramoto L, Guy P, Bettger JP, Sobolev B. Prognostic factors of in-hospital complications after hip fracture surgery: a scoping review. Osteoporos Int 2019; 30:1339-1351. [PMID: 31037362 DOI: 10.1007/s00198-019-04976-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/14/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION To examine prognostic factors that influence complications after hip fracture surgery. To summarize proposed underlying mechanisms for their influence. METHODS We reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English on January 2008-January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed the extraction with accuracy checks by the second reviewer. We summarized the extent, nature, and proposed underlying mechanisms for the prognostic factors of complications narratively and in a dependency graph. RESULTS We identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors-dehydration, anemia, hypotension, heart rate variability, pressure risk, nutrition, and indwelling catheter use; and 7 process factors-time to surgery, anesthetic type, transfusion strategy, orthopedic versus geriatric/co-managed care, multidisciplinary care pathway, and potentially modifiable during index hospitalization. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies. CONCLUSIONS Most factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualization of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.
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Affiliation(s)
- K J Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK.
| | - E M Guerrero
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - D Tainter
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - B Dial
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - R Milton-Cole
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - J A Blair
- Department of Orthopaedics and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX, USA
| | - J Alexander
- Department of Rehabilitation Sciences, Kingston & St George's University of London, London, UK
| | - P Swamy
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - L Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - P Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - J P Bettger
- Department of Orthopaedic Surgery, Duke University Medical Centre, Durham, NC, USA
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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10
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Second Place Award: Residents or hip surgeons for the treatment of displaced femoral neck fractures? A 10-year survivorship rate analysis. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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11
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Beaupre L, Sobolev B, Guy P, Kim JD, Kuramoto L, Sheehan KJ, Sutherland JM, Harvey E, Morin SN. Discharge destination following hip fracture in Canada among previously community-dwelling older adults, 2004-2012: database study. Osteoporos Int 2019; 30:1383-1394. [PMID: 30937483 DOI: 10.1007/s00198-019-04943-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
UNLABELLED Little is known about post-acute care following hip fracture surgery. We investigated discharge destinations from surgical hospitals for nine Canadian provinces. We identified significant heterogeneity in discharge patterns across provinces suggesting different post-acute recovery pathways. Further work is required to determine the impact on patient outcomes and health system costs. INTRODUCTION To examine discharge destinations by provinces in Canada, adjusting for patient, injury, and care characteristics. METHODS We analyzed population-based hospital discharge abstracts from a national administrative database for community-dwelling patients who underwent hip fracture surgery between 2004 and 2012 in Canada. Discharge destination was categorized as rehabilitation, home, acute care, and continuing care. Multinomial logistic regression modeling compared proportions of discharge to rehabilitation, acute care, and continuing care versus home between each province and Ontario. Adjusted risk differences and risk ratios were estimated. RESULTS Of 111,952 previously community-dwelling patients aged 65 years or older, 22.5% were discharged to rehabilitation, 31.6% to home, 27.0% to acute care, and 18.2% to continuing care, with significant variation across provinces (p < 0.001). The proportion of discharge to rehabilitation ranged from 2.4% in British Columbia to 41.0% in Ontario while the proportion discharged home ranged from 20.3% in Prince Edward Island to 52.2% in British Columbia. The proportion of discharge to acute care ranged from 15.2% in Ontario to 58.8% in Saskatchewan while the proportion discharged to continuing care ranged from 9.3% in Manitoba and Prince Edward Island to 22.9% in New Brunswick. Adjusting for hospital type changed the direction of the provincial effect on discharge to continuing care in two provinces, but statistical significance remained consistent with the primary analysis. CONCLUSIONS Discharge destination from the surgical hospital after hip fracture is highly variable across nine Canadian provinces. Further work is required to determine the impact of this heterogeneity on patient outcomes and health system costs.
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Affiliation(s)
- L Beaupre
- University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada.
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - P Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - J D Kim
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - L Kuramoto
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - K J Sheehan
- Academic Department of Physiotherapy, Division of Health and Social Care Research, King's College London, London, UK
| | - J M Sutherland
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
| | - E Harvey
- McGill University, Montreal, Canada
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Higashikawa T, Shigemoto K, Goshima K, Usuda D, Okuro M, Moriyama M, Inujima H, Hangyou M, Usuda K, Morimoto S, Matsumoto T, Takashima S, Kanda T, Sawaguchi T. Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort. Medicine (Baltimore) 2019; 98:e16023. [PMID: 31192952 PMCID: PMC6587656 DOI: 10.1097/md.0000000000016023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ± 7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.
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Affiliation(s)
- Toshihiro Higashikawa
- Department of Geriatric Medicine, Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi
| | - Kenji Shigemoto
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | - Kenichi Goshima
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | | | - Masashi Okuro
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa
| | - Manabu Moriyama
- Department of Urology, Kanazawa Medical University Himi Municipal Hospital, Kurakawa, Himi
| | - Hiromi Inujima
- Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | | | - Kimiko Usuda
- Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
| | - Shigeto Morimoto
- Department of Geriatric Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa
| | - Tadami Matsumoto
- Department of Orthopedic Medicine, Kanazawa Medical University, Uchinada, Kahoku-gun, Ishikawa, Japan
| | | | | | - Takeshi Sawaguchi
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Hokubumachi, Imaizumi, Toyama
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13
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The impact of time to surgery after hip fracture on mortality at 30- and 90-days: Does a single benchmark apply to all? Injury 2019; 50:950-955. [PMID: 30948037 DOI: 10.1016/j.injury.2019.03.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/17/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Delays to surgery after hip fracture have been associated with mortality Uncertainty remains as to what timing benchmark should be utilized as a marker of quality of care and how other patient factors might also influence the impact of time to surgery on mortality. The goal of this study was to determine how time to surgery affects 30- and 90-day mortality by age and to explore the impact of preoperative comorbid burden and sex. PARTICIPANTS We used population-based administrative data from a Canadian province collected from 01April2008 to 31March2015. Of 12,713 Albertans 50-years and older who experienced a hip fracture and underwent surgery within 100 h of admission, 11,996 (94.8%) provided data. METHODS Time to surgery was analyzed in hours from admission to surgery. Age and the interaction between age and time to surgery were evaluated using logistic regression. Charlson co-morbidity score and sex were also considered in the analysis. Survival was evaluated at 30-and 90-days post hip fracture using a provincial registry. RESULTS The average age of the cohort was 79.6 ± 11.2 years and 8,412 (70.1%) were female. Overall, 586 (4.9%) patients died within 30-days and 1,023 (8.5%) died within 90-days of hip fracture. Mortality increased significantly with increasing time to surgery (30-day mortality odds ratio [OR] = 1.03; 95%CI 1.01-1.05: 90-day mortality OR = 1.03; 95% CI 1.01-1.04). Mortality also increased substantially with increasing age; those ≥85 years were 19.63 (95% CI 6.83-67.33) and 15.66 (95%CI 7.20-37.16) times the odds more likely to die relative to those between 50-64 years of age at 30-days and 90-days postoperatively respectively. Further, those who were ≥85 years were more significantly affected by increasing time to surgery than those who were 50-64 years of age at both 30-days (p = 0.04) and 90-days (p = 0.025) post-fracture. Males and those with a higher comorbid burden also had higher odds of dying after controlling for time to surgery (p < 0.001) CONCLUSION: Time to surgery following hip fracture may have a differential effect on 30- and 90-day survival dependent on age. Older patients appear to be at higher risk of dying with surgical delays than younger patients.
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Schermann H, Gurel R, Rotman D, Chechik O, Sternheim A, Salai M, Ben-Tov T, Kadar A. Regulatory Measures Expedited Hip Fracture Surgery Without Lowering Overall Patient Mortality. J Am Geriatr Soc 2018; 67:777-783. [DOI: 10.1111/jgs.15721] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Haggai Schermann
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Ron Gurel
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Dani Rotman
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Ofir Chechik
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Amir Sternheim
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Moshe Salai
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Tomer Ben-Tov
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Assaf Kadar
- Department of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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15
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Sheehan KJ, Levy AR, Sobolev B, Guy P, Tang M, Kuramoto L, Sutherland JM, Beaupre L, Morin SN, Harvey E, Bradley N. Operationalising a conceptual framework for a contiguous hospitalisation episode to study associations between surgical timing and death after first hip fracture: a Canadian observational study. BMJ Open 2018; 8:e020372. [PMID: 30530471 PMCID: PMC6287122 DOI: 10.1136/bmjopen-2017-020372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We describe steps to operationalise a published conceptual framework for a contiguous hospitalisation episode using acute care hospital discharge abstracts. We then quantified the degree of bias induced by a first abstract episode, which does not account for hospital transfers. DESIGN Retrospective observational study. SETTING All acute care hospitals in nine Canadian provinces. PARTICIPANTS We retrieved acute hospitalisation discharge abstracts for 189 448 patients aged 65 years and older admitted to acute care with hip fracture between 2003 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES The percentage of patients treated surgically, delayed to surgery (defined as two or more days after admission) and dying, between contiguous hospitalisation episodes and the first abstract episodes of care. RESULTS Using contiguous hospitalisation episodes, 91.6% underwent surgery, 35.7% were delayed two or more days after admission and 6.7% died postoperatively, whereas, using the first abstract only, these percentages were 83.7%, 32.5% and 6.5%, respectively. CONCLUSION We demonstrate that not accounting for hospital transfers when evaluating the association between surgical timing and death underestimates reporting of the percentage of patients treated surgically and delayed to surgery by 9%, and the percentage who die after surgery by 3%. Researchers must be aware of this potential and avoidable bias as, depending on the purpose of the study, erroneous inferences may be drawn.
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Affiliation(s)
- Katie Jane Sheehan
- Department of Population Health Sciences, School of Population Health and Environmental Sciences, Kings College London, London, UK
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Tang
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lauren Beaupre
- Department of Physical Therapy and Division of Orthopaedic Surgery, University of Alberta, Alberta, Edmonton, Canada
| | - Suzanne N Morin
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Edward Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, Québec, Canada
| | - Nick Bradley
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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16
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Pincus D, Wasserstein D, Ravi B, Huang A, Paterson JM, Jenkinson RJ, Kreder HJ, Nathens AB, Wodchis WP. Medical Costs of Delayed Hip Fracture Surgery. J Bone Joint Surg Am 2018; 100:1387-1396. [PMID: 30106820 DOI: 10.2106/jbjs.17.01147] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs. METHODS We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days). RESULTS The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours. CONCLUSIONS Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery. LEVEL OF EVIDENCE Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Pincus
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - David Wasserstein
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bheeshma Ravi
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Anjie Huang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - Richard J Jenkinson
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Hans J Kreder
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery B Nathens
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Division of Orthopaedic Surgery, Department of Surgery (D.P., D.W., B.R., R.J.J., H.J.K., and A.B.N.) and the Institute of Health Policy, Management and Evaluation (D.P., R.J.J., H.J.K., A.B.N., and W.P.W.), University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
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17
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Lee SY, Beom J, Kim BR, Lim SK, Lim JY. Comparative effectiveness of fragility fracture integrated rehabilitation management for elderly individuals after hip fracture surgery: A study protocol for a multicenter randomized controlled trial. Medicine (Baltimore) 2018; 97:e10763. [PMID: 29768364 PMCID: PMC5976332 DOI: 10.1097/md.0000000000010763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Although it is essential to provide comprehensive rehabilitation after hip fracture to restore the patient to preoperative physical functioning, feasibility issues remain. Here, we describe a protocol for a randomized controlled trial (RCT) to evaluate the effectiveness of fragility fracture integrated rehabilitation management (FIRM) for elderly individuals after hip fracture surgery. We also examine the feasibility of applying FIRM in a chronic-care hospital or community-based setting. METHODS AND ANALYSIS Elderly patients will be randomly assigned to either the FIRM, conventional, or control group for a 2-week intervention period following hip fracture surgery. The primary outcome of this study is Koval walking ability. All functional outcomes will be measured 1 and 3 weeks, 3, 6, and 12 months after the surgical intervention. Researchers will be blind to group allocation, and participants will be blind to outcome. A sample size of 282 participants will be necessary to demonstrate the effect of the FIRM program. After the RCT has been conducted in 3 core hospitals, FIRM will be applied in 6 community-based local hospitals to investigate the feasibility of the program. The data will be analyzed using the intention-to-treat principle. TRIAL REGISTRATION NUMBER NCT03430193.
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Affiliation(s)
- Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center Department of Physical Medicine and Rehabilitation, Chung-Ang University Hospital, Seoul Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University College of Medicine, Jeju Department of Rehabilitation Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
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18
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Sheehan KJ, Filliter C, Sobolev B, Levy AR, Guy P, Kuramoto L, Kim JD, Dunbar M, Morin SN, Sutherland JM, Jaglal S, Harvey E, Beaupre L, Chudyk A. Time to surgery after hip fracture across Canada by timing of admission. Osteoporos Int 2018; 29:653-663. [PMID: 29214329 DOI: 10.1007/s00198-017-4333-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/29/2017] [Indexed: 10/18/2022]
Abstract
UNLABELLED The extent of Canadian provincial variation in hip fracture surgical timing is unclear. Provinces performed a similar proportion of surgeries within three inpatient days after adjustment. Time to surgery varied by timing of admission across provinces. This may reflect different approaches to providing access to hip fracture surgery. INTRODUCTION The aim of this study was to compare whether time to surgery after hip fracture varies across Canadian provinces for surgically fit patients and their subgroups defined by timing of admission. METHODS We retrieved hospitalization records for 140,235 patients 65 years and older, treated surgically for hip fracture between 2004 and 2012 in Canada (excluding Quebec). We studied the proportion of surgeries on admission day and within 3 inpatient days, and times required for 33%, 66%, and 90% of surgeries across provinces and by subgroups defined by timing of admission. Differences were adjusted for patient, injury, and care characteristics. RESULTS Overall, provinces performed similar proportions of surgeries within the recommended three inpatient days, with all provinces requiring one additional day to perform the recommended 90% of surgeries. Prince Edward Island performed 7.0% more surgeries on admission day than Ontario irrespective of timing of admission (difference = 7.0; 95% CI 4.0, 9.9). The proportion of surgeries on admission day was 6.3% lower in Manitoba (difference = - 6.3; 95% CI - 12.1, - 0.6), and 7.7% lower in Saskatchewan (difference = - 7.7; 95% CI - 12.7, - 2.8) compared to Ontario. These differences persisted for late weekday and weekend admissions. The time required for 33%, 66%, and 90% of surgeries ranged from 1 to 2, 2-3, and 3-4 days, respectively, across provinces by timing of admission. CONCLUSIONS Provinces performed similarly with respect to recommended time for hip fracture surgery. The proportion of surgeries on admission day, and time required to complete 33% and 66% of surgeries, varied across provinces and by timing of admission. This may reflect different provincial approaches to providing access to hip fracture surgery.
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Affiliation(s)
- K J Sheehan
- Academic Department of Physiotherapy, School of Population Health and Environmental Sciences, Guy's Campus, King's College London, London, UK.
| | - C Filliter
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - A R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - P Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, BC, Canada
| | - L Kuramoto
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - J D Kim
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Dunbar
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS, Canada
| | - S N Morin
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - J M Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - S Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - E Harvey
- Division of Orthopaedic Surgery, McGill University, Montreal, QC, Canada
| | - L Beaupre
- Department of Physical Therapy and Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada
| | - A Chudyk
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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19
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Sheehan KJ, Sobolev B, Guy P. Mortality by Timing of Hip Fracture Surgery: Factors and Relationships at Play. J Bone Joint Surg Am 2017; 99:e106. [PMID: 29040134 DOI: 10.2106/jbjs.17.00069] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In hip fracture care, it is disputed whether mortality worsens when surgery is delayed. This knowledge gap matters when hospital managers seek to justify resource allocation for prioritizing access to one procedure over another. Uncertainty over the surgical timing-death association leads to either surgical prioritization without benefit or the underuse of expedited surgery when it could save lives. The discrepancy in previous findings results in part from differences between patients who happened to undergo surgery at different times. Such differences may produce the statistical association between surgical timing and death in the absence of a causal relationship. Previous observational studies attempted to adjust for structure, process, and patient factors that contribute to death, but not for relationships between structure and process factors, or between patient and process factors. In this article, we (1) summarize what is known about the factors that influence, directly or indirectly, both the timing of surgery and the occurrence of death; (2) construct a dependency graph of relationships among these factors based explicitly on the existing literature; (3) consider factors with a potential to induce covariation of time to surgery and the occurrence of death, directly or through the network of relationships, thereby explaining a putative surgical timing-death association; and (4) show how age, sex, dependent living, fracture type, hospital type, surgery type, and calendar period can influence both time to surgery and occurrence of death through chains of dependencies. We conclude by discussing how these results can inform the allocation of surgical capacity to prevent the avoidable adverse consequences of delaying hip fracture surgery.
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Affiliation(s)
- Katie Jane Sheehan
- 1Department of Physiotherapy, Division of Health and Social Care Research, Kings College London, London, United Kingdom 2School of Population and Public Health (B.S.) and Centre for Hip Health and Mobility (P.G.), University of British Columbia, Vancouver, British Columbia, Canada
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20
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Abstract
OBJECTIVES It is disputed whether the time a patient waits for surgery after hip fracture increases the risk of in-hospital death. This uncertainty matters as access to surgery following hip fracture may be underprioritised due to a lack of definitive evidence. Uncertainty in the available evidence may be due to differences in characteristics of patients, their injury and their care. We summarised the literature on patients and system factors associated with time to surgery, and collated proposed mechanisms for the associations. METHODS We used the framework developed by Arksey and O'Malley and Levac et al for synthesis of factors and mechanisms of time to surgery after hip fracture in adults aged >50 years, published in English, between 1 January 2000 and 28 February 2017, and indexed in MEDLINE, EMBASE, CINAHL or Ageline. Proposed mechanisms for reported associations were extracted from discussion sections. RESULTS We summarised evidence from 26 articles that reported on 24 patient and system factors of time to surgery post hip fracture. In total, 16 factors were reported by only one article. For 16 factors we found proposed mechanisms for their association with time to surgery which included surgical readiness, available resources, prioritisation and out-of-hours admission. CONCLUSIONS We identified patient and system factors associated with time to surgery after hip fracture. This new knowledge will inform evaluation of the putative timing-death association. Future interventions should be designed to influence factors with modifiable mechanisms for delay.
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Affiliation(s)
- Katie J Sheehan
- Academic Department of Physiotherapy, Division of Health and Social Care Research, King's College London, London, UK
| | - Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | - Pierre Guy
- Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
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21
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Coventry LL, Pickles S, Sin M, Towell A, Giles M, Murray K, Twigg DE. Impact of the Orthopaedic Nurse Practitioner role on acute hospital length of stay and cost-savings for patients with hip fracture: A retrospective cohort study. J Adv Nurs 2017; 73:2652-2663. [DOI: 10.1111/jan.13330] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Linda L. Coventry
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands WA Australia
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Perth WA Australia
| | - Sharon Pickles
- Department of Orthopaedics; Sir Charles Gairdner Hospital; Nedlands WA Australia
| | - Michelle Sin
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands WA Australia
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Perth WA Australia
| | - Amanda Towell
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands WA Australia
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Perth WA Australia
| | - Margaret Giles
- School of Business and Law; Edith Cowan University; Joondalup Perth WA Australia
| | - Kevin Murray
- School of Population Health; The University of Western Australia; Nedlands WA Australia
| | - Diane E. Twigg
- Centre for Nursing Research; Sir Charles Gairdner Hospital; Nedlands WA Australia
- School of Nursing and Midwifery; Edith Cowan University; Joondalup Perth WA Australia
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22
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Sheehan KJ, Sobolev B, Guy P, Tang M, Kuramoto L, Belmont P, Blair JA, Sirett S, Morin SN, Griesdale D, Jaglal S, Bohm E, Sutherland JM, Beaupre L. Feasibility of administrative data for studying complications after hip fracture surgery. BMJ Open 2017; 7:e015368. [PMID: 28473519 PMCID: PMC5623359 DOI: 10.1136/bmjopen-2016-015368] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE There is limited information in administrative databases on the occurrence of serious but treatable complications after hip fracture surgery. This study sought to determine the feasibility of identifying the occurrence of serious but treatable complications after hip fracture surgery from discharge abstracts by applying the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 4 (PSI-4) case-finding tool. METHODS We obtained Canadian Institute for Health Information discharge abstracts for patients 65 years or older, who were surgically treated for non-pathological first hip fracture between 1 January 2004 and 31 December 2012 in Canada, except for Quebec. We applied specifications of AHRQ Patient Safety Indicators 04, Version 5.0 to identify complications from hip fracture discharge abstracts. RESULTS Out of 153 613 patients admitted with hip fracture, we identified 12 383 (8.1%) patients with at least one postsurgical complication. From patients with postsurgical complications, we identified 3066 (24.8%) patient admissions to intensive care unit. Overall, 7487 (4.9%) patients developed pneumonia, 1664 (1.1%) developed shock/myocardial infarction, 651 (0.4%) developed sepsis, 1862 (1.1%) developed deep venous thrombosis/pulmonary embolism and 1919 (1.3%) developed gastrointestinal haemorrhage/acute ulcer. CONCLUSIONS We report that 8.1% of patients developed at least one inhospital complication after hip fracture surgery in Canada between 2004 and 2012. The AHRQ PSI-4 case-finding tool can be considered to identify these serious complications for evaluation of postsurgical care after hip fracture.
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Affiliation(s)
- Katie Jane Sheehan
- Department of Physiotherapy, Division of Health and Social Care, Kings College, London, UK
| | - Boris Sobolev
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
| | - Pierre Guy
- Department of Orthopedics, University of British Columbia, Vancouver, Canada
| | - Michael Tang
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - Lisa Kuramoto
- Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - Philip Belmont
- Department of Orthopaedic surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Cente, El Paso, Texas, USA
| | - James A Blair
- Department of Orthopaedic surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Cente, El Paso, Texas, USA
| | - Susan Sirett
- Decision Support, Vancouver Coastal Health Authority, Vancouver, Canada
| | | | - Donald Griesdale
- Departments of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Susan Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Eric Bohm
- Division of Orthopaedic Surgery and Center for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Jason M Sutherland
- School of Population & Public Health, University of British Columbia, Vancouver, Canada
| | - Lauren Beaupre
- Department of Physical Therapy and the Division of Orthopaedic Surgery, University of Alberta, Edmonton, Canada
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23
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Sobolev B, Guy P, Sheehan KJ, Bohm E, Beaupre L, Morin SN, Sutherland JM, Dunbar M, Griesdale D, Jaglal S, Kuramoto L. Hospital mortality after hip fracture surgery in relation to length of stay by care delivery factors: A database study. Medicine (Baltimore) 2017; 96:e6683. [PMID: 28422882 PMCID: PMC5406098 DOI: 10.1097/md.0000000000006683] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Two hypotheses were offered for the effect of shorter hospital stays on mortality after hip fracture surgery: worsening the quality of care and shifting death occurrence to postacute settings.We tested whether the risk of hospital death after hip fracture surgery differed across years when postoperative stays shortened, and whether care factors moderated the association.Analysis of acute hospital discharge abstracts for subgroups defined by hospital type, bed capacity, surgical volume, and admission time.153,917 patients 65 years or older surgically treated for first hip fracture.Risk of hospital death.We found a decrease in the 30-day risk of hospital death from 7.0% (95%CI: 6.6-7.5) in 2004 to 5.4% (95%CI: 5.0-5.7) in 2012, with an adjusted odds ratio [OR] 0.71 (95%CI: 0.63-0.80). In subgroup analysis, only large community hospitals showed the reduction of ORs by calendar year. No trend was observed in teaching and medium community hospitals. By 2012, the risk of death in large higher volume community hospitals was 34% lower for weekend admissions, OR = 0.66 (95%CI: 0.46-0.95) and 39% lower for weekday admissions, OR = 0.61 (95%CI: 0.40-0.91), compared to 2004. In large lower volume community hospitals, the 2012 risk was 56% lower for weekend admissions, OR = 0.44 (95%CI: 0.26-0.75), compared to 2004.The risk of hospital death after hip fracture surgery decreased only in large community hospitals, despite universal shortening of hospital stays. This supports the concern of worsening the quality of hip fracture care due to shorter stays.
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Affiliation(s)
- Boris Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Pierre Guy
- Department of Orthopedics, University of British Columbia
| | - Katie J. Sheehan
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Eric Bohm
- Division of Orthopaedic Surgery and Center for Healthcare Innovation, University of Manitoba, Winnipeg
| | - Lauren Beaupre
- Departments of Physical Therapy and Division of Orthopaedic Surgery, University of Alberta, Edmonton
| | | | - Jason M. Sutherland
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Michael Dunbar
- Division of Orthopaedic Surgery, Dalhousie University, Halifax
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver
| | - Susan Jaglal
- Department of Physical Therapy, University of Toronto, Toronto
| | - Lisa Kuramoto
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
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24
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Sheehan KJ, Sobolev B, Guy P, Kuramoto L, Morin SN, Sutherland JM, Beaupre L, Griesdale D, Dunbar M, Bohm E, Harvey E. In-hospital mortality after hip fracture by treatment setting. CMAJ 2016; 188:1219-1225. [PMID: 27754892 DOI: 10.1503/cmaj.160522] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Where patients with hip fracture undergo treatment may influence their outcome. We compared the risk of in-hospital death after hip fracture by treatment setting in Canada. METHODS We examined all discharge abstracts from the Canadian Institute for Health Information with diagnosis codes for hip fracture involving patients 65 years and older who were admitted to hospital with a nonpathological first hip fracture between Jan. 1, 2004, and Dec. 31, 2012, in Canada (excluding Quebec). We compared the risk of in-hospital death, overall and after surgery, between teaching hospitals and community hospitals of various bed capacities, accounting for variation in length of stay. RESULTS Compared with the number of deaths per 1000 admissions at teaching hospitals, there were an additional 3 (95% confidence interval [CI] 1-6), 14 (95% CI 10-18) and 43 (95% CI 35-51) deaths per 1000 admissions at large, medium and small community hospitals, respectively. For the risk of in-hospital death overall, the adjusted odds ratios (ORs) were 1.05 (95% CI 0.99-1.11), 1.16 (95% CI 1.09-1.24) and 1.44 (95% CI 1.31-1.57) at large, medium and small community hospitals, respectively, compared with teaching hospitals. For the risk of postsurgical death in hospital, the adjusted ORs were 1.06 (95% CI 1.00-1.13), 1.13 (95% CI 1.04-1.23) and 1.18 (95% CI 0.87-1.60) at large, medium and small community hospitals, respectively. INTERPRETATION Compared with teaching hospitals, the risk of in-hospital death among patients with hip fracture was higher at medium and small community hospitals, and the risk of in-hospital death after surgery was higher at medium community hospitals. No differences were found between teaching and large community hospitals. Future research should examine the role of volume, demand and bed occupancy for observed differences.
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Affiliation(s)
- Katie J Sheehan
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que.
| | - Boris Sobolev
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Pierre Guy
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Lisa Kuramoto
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Suzanne N Morin
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Jason M Sutherland
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Lauren Beaupre
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Donald Griesdale
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Michael Dunbar
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Eric Bohm
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
| | - Edward Harvey
- School of Population and Public Health (Sheehan, Sobolev, Sutherland) and Department of Orthopedics (Guy), University of British Columbia, Vancouver, BC; Centre for Clinical Epidemiology and Evaluation (Kuramoto), Vancouver Coastal Health Research Institute, Vancouver, BC; Department of Medicine (Morin), McGill University, Montréal, Que.; Department of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Department of Anesthesiology, Pharmacology and Therapeutics (Griesdale), University of British Columbia, Vancouver, BC; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Division of Orthopaedic Surgery and Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey), McGill University, Montréal, Que
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