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Kelly M, Donovan RL, Dailiana ZH, Pape HC, Chana-Rodríguez F, Pari C, Ponsen KJ, Cattaneo S, Belluati A, Contini A, Gómez-Vallejo J, Casallo-Cerezo M, Willinge GJ, van Veen RN, Gosling JC, Papadakis SA, Iliopoulos E. Rehabilitation after musculoskeletal injury: European perspective. OTA Int 2024; 7:e330. [PMID: 39114372 PMCID: PMC11301633 DOI: 10.1097/oi9.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 08/10/2024]
Abstract
Trauma is one of the main causes of death in younger people and ongoing disability worldwide. In Europe, while there is generally good organization of trauma reception and acute treatment, rehabilitation from major musculoskeletal injuries is less well defined and provided. This article documents the diverse approaches to rehabilitation after major injury in 6 European nations. The recognition of need is universal, but achieving a robust rehabilitation strategy is more elusive across the varying health care systems. Switzerland has the most robust service in the insured population. In the other countries, particularly where there is a reliance on public institutes, this provision is at best patchy. In the Netherlands, innovative patient-empowering strategies have gained traction with notable success, and in the United Kingdom, a recent randomized trial also showed this approach to be reproducible and robust. Overall, there is a clear need for learning across the national systems and implementation of a minimum set of standards.
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Anoushiravani AA, Posner AD, Gheewala RA, Feng JE, Chisena EN. A 7-year perspective on femoral neck fracture management in New York State-Do Level 1 trauma centers provide better care? Injury 2023:S0020-1383(23)00361-3. [PMID: 37183086 DOI: 10.1016/j.injury.2023.04.025] [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: 08/01/2022] [Revised: 02/20/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Patients with femoral neck fractures are at a substantial risk for medical complications and all-cause mortality. Given this trend, our study aims to evaluate postoperative outcomes and the economic profile associated with femoral neck fractures managed at level-1 (L1TC) and non-level-1-trauma centers (nL1TC). METHODS The SPARCS database was queried for all geriatric patients sustaining atraumatic femoral neck fractures within New York State between 2011 and 2017. Patients were then divided into two cohorts depending on the treating facility's trauma center designation: L1TC versus nL1TC. Patient samples were evaluated for trends and relationships using descriptive analysis, Student's t-tests, and Chi-squared. Multivariable linear-regressions were utilized to assess the effect of trauma center designation and potential confounders on patient mortality and inpatient healthcare expenses. RESULTS In total, 44,085 femoral neck fractures operatively managed at 161 medical centers throughout New York during a 7-year period. 4,974 fractures were managed at L1TC while 39,111 were treated at nL1TC. Following multivariate regression analysis, management at L1TC was the most significant cost driver, resulting in an average increased cost of $6,330.74 per fracture. CONCLUSION Our results suggest that femoral neck fractures treated at L1TC have more comorbidities, higher in-hospital mortality, longer LOS, and greater hospital costs.
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Affiliation(s)
- Afshin A Anoushiravani
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA.
| | - Andrew D Posner
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - Rohan A Gheewala
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
| | - James E Feng
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, 3535 West 13 Mile Road, Suite 742, Royal Oak, MI 48073, USA
| | - Ernest N Chisena
- Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland Avenue, Albany, NY 12208, USA
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López-Martín N, Escalera-Alonso J, Thuissard-Vasallo IJ, Andreu-Vázquez C, Bielza-Galindo R. [Result of the update of the clinical pathway for hip fracture in the elderly at a university hospital in Madrid]. Rev Esp Geriatr Gerontol 2023; 58:61-67. [PMID: 36804952 DOI: 10.1016/j.regg.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/13/2022] [Accepted: 01/18/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Orthogeriatric management with clinical pathways (CP) in hip fracture (HF) has been shown to be superior to other models. We studied whether updating the CP, through prioritization of admission and surgery, improvement in the prevention and treatment of delirium, management of anticoagulants and antiplatelet agents and the use of perioperative peripheral nerve block, modifies surgical delay, stay, readmissions, mortality, suffering delirium and functional status at discharge. MATERIAL AND METHOD A retrospective observational study of unicenter cohorts of 468 patients with HF, 220 from 2016 (old VC) and 248 from 2019 (new VC). The variables are: intervention in the first 48hours, surgical delay (hours), stay (days), stay less than 15 days, delirium, functional loss at discharge (Barthel prefracture scale less Barthel scale at discharge), readmission at one month, and mortality at admission, month and year. RESULTS Median age: 87.0 [interquartile range 8.0], mostly women (76.7%). Significantly, with the new VC, there was a greater number of patients operated on in the first 48hours (27,7% vs 36,8% p=0.036), less surgical delay (72.5 [47,5-110,5] vs 64.0 [42,0-88,0] p<0.001), shorter stay (10,0 [7,0-13,0] vs 8,0 [6,0-11,0] p<0.001), greater number of discharges in 15 days (78,2% vs 91,5% p<0.001), lower delirium (54,1% vs 43,5% p=0.023). No significant changes in readmissions, functional loss at discharge, mortality at admission, 3 months or year. CONCLUSIONS Updating the VC brings benefits to the patient (less surgical delay, equal functional status at discharge with fewer days of admission) and benefits in management (lower admission) without modifying mortality.
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Affiliation(s)
- Néstor López-Martín
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España.
| | - Javier Escalera-Alonso
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
| | - Israel John Thuissard-Vasallo
- Facultad de Ciencias Biomédicas y de la Salud, Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, España
| | - Cristina Andreu-Vázquez
- Facultad de Ciencias Biomédicas y de la Salud, Departamento de Medicina, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, España
| | - Rafael Bielza-Galindo
- Sección de Geriatría, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
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Complex Orthopaedic Trauma Is Shifting Away From Level I to Non-Level I Trauma Centers: An Analysis of the National Trauma Data Bank. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202302000-00005. [PMID: 36749712 PMCID: PMC9907928 DOI: 10.5435/jaaosglobal-d-22-00288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION An increasing number of fellowship-trained orthopaedic trauma surgeons are working in non-Level I centers. This study aimed to examine trends of management of complex orthopaedic trauma in Level I centers versus non-Level I centers and its potential effect on patient outcomes. METHODS Data from the National Trauma Data Bank from 2008 to 2017 were analyzed. Non-Level I to Level I center ratios for complex fractures and complication rates, median hours to procedure for time-sensitive fractures, and uninsured/underinsured rates of Level I and non-Level I centers were recorded. RESULTS Three hundred one thousand patients were included. A statistically significant downward trend was identified in the percent of all complex orthopaedic trauma at Level I centers and per-hospital likelihood of seeing a complex orthopaedic fracture in a Level I versus non-Level I hospital. Per-hospital complication rates were consistently lower in non-Level I hospitals after controlling for injury severity and payer mix. Time-sensitive fractures were treated earlier in non-Level I centers. DISCUSSION This study demonstrates a reduction of complex trauma treatment in Level I centers that did not translate to adverse effects on patient outcomes. Policymakers should notice this trend to ensure the continued quality of orthopaedic trauma training and maintenance of expertise in complex fracture management.
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Ang D, Anglen J, Ziglar M, Armstrong J, Offner P, McKenney M, Plurad D, Flaherty S, Gonzalez E, Liu H, Danish M, McCormack G, Nash J, Nagy R, Carrick M. A multicenter study on definitive surgery for isolated hip fracture within 24 hours. J Trauma Acute Care Surg 2021; 90:113-121. [PMID: 33003017 DOI: 10.1097/ta.0000000000002951] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Isolated hip fractures (IHFs) in the elderly are high-frequency, life-altering events. Definitive surgery ≤24 hours of admission is associated with improved outcomes. An IHF process management guideline (IHF-PMG) to expedite definitive surgery ≤24 hours was developed for a multihospital network. We report on its feasibility and subsequent patient outcomes. METHODS This is a prospective multicenter cohort study, involving 85 levels 1, 2, 3, and 4 trauma centers. Patients with an IHF between 65 and 100 years old were studied. Four cohorts were examined: (1) hospitals that did not implement any PMG, (2) hospitals that used their own PMG, (3) hospitals that partially used the network IHF-PMG, and (4) hospitals that used the network's IHF-PMG. Multivariable logistic regression with reliability adjustment was used to calculate the expected value of observed to expected (O/E) mortality. Statistical significance was defined as p < 0.05. RESULTS Data on 24,457 IHF were prospectively collected. Following implementation of the IHF-PMG, overall IHF O/E mortality ratios decreased within the hospital network, from 1.13 in 2017 to 0.87 in 2018 and 0.86 in 2019. Hospitals that developed their own IHF-PMG or used the enterprise-wide IHF-PMG had the lowest inpatient O/E mortality at 0.59 and 0.65, respectively. CONCLUSION Goal-directed IHF-PMG for definitive surgery ≤24 hours was implemented across a large hospital network. The IHF-PMG was associated with lower inpatient mortality. LEVEL OF EVIDENCE Therapeutic/ Care management, Level III.
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Affiliation(s)
- Darwin Ang
- From the Ocala Health Trauma, Ocala Regional Medical Center (D.A., H.L.), Ocala, Florida; Department of Surgery, University of South Florida (D.A., J. Armstrong), Tampa, Florida; University of Central Florida, College of Medicine (D.A.), Orlando, Florida; Division of Orthopedic Surgery, Mcleod Regional Medical Center (J. Anglen), Florence, South Carolina; Trauma Clinical Services Group, Hospital Corporation of America (M.Z., M.D., G.M., J.N.), Nashville, Tennessee; Department of Trauma, Sky Ridge Medical Center (P.O.), Lone Tree, Colorado; Department of Trauma, Kendall Regional Medical Center (M.M.), Miami, Florida; Department of Trauma, Riverside Community Hospital (D.P.), Riverside, California; Department of Trauma, Del Sol Medical Center (S.F.), El Paso, Texas; Department of Trauma, South Austin Medical Center (E.G.), Austin, Texas; Department of Trauma, TriStar Skyline Medical Center (R.N.), Nashville, Tennessee; and Department of Trauma, Medical City (M.C.), Plano, Texas
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Hietbrink F, Houwert RM, van Wessem KJP, Simmermacher RKJ, Govaert GAM, de Jong MB, de Bruin IGJ, de Graaf J, Leenen LPH. The evolution of trauma care in the Netherlands over 20 years. Eur J Trauma Emerg Surg 2019; 46:329-335. [PMID: 31760466 PMCID: PMC7113214 DOI: 10.1007/s00068-019-01273-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022]
Abstract
Introduction In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures). Materials and Methods In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated. Results It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement. Conclusion Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Roderick M Houwert
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rogier K J Simmermacher
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Geertje A M Govaert
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Ivar G J de Bruin
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Johan de Graaf
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Loek P H Leenen
- Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Antunes Filho J, Silva ADDCE, Mendes Junior AF, Pereira FJC, Oppe IG, Loures EDA. Predictive Factors of Death after Surgery for Treatment of Proximal Femoral Fracture. Rev Bras Ortop 2019; 54:402-407. [PMID: 31435106 PMCID: PMC6701965 DOI: 10.1055/s-0039-1692179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 08/06/2018] [Indexed: 10/29/2022] Open
Abstract
Objective To evaluate predictive factors of death in patients aged ≥ 70 years old with proximal femoral fracture (PFF) submitted to surgical treatment. Methods An analysis of medical records by creating a retrospective cohort with a 6-month follow-up. A total of 124 charts were analyzed after applying the inclusion and exclusion criteria. All of the patients were treated by a single orthopedic surgeon under uniform conditions. Results The mortality rate was of 34.7%, and the most common profile was female, 85 years old, and with at least 1 comorbidity. Patients > 85 years old, hospitalized for > 7 days, with at least 1 comorbidity, and staying at the intensive care unit (ICU) had a higher risk of death (2, 2.5, 4, and 4 times higher, respectively). Conclusion Regarding the death outcome, although we did not find a statistically significant difference in the topography of the lesion and in its behavior in its coexistence with ICU hospitalization, we believe that further investigations under this perspective are required in a population with the studied profile.
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Affiliation(s)
- Jurandir Antunes Filho
- Departamento de Sistema Musculoesquelético, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | | | | | | | - Igor Gerdi Oppe
- Departamento de Sistema Musculoesquelético, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
| | - Elmano de Araújo Loures
- Departamento de Sistema Musculoesquelético, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
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Yli-Kyyny TT, Sund R, Heinänen M, Malmivaara A, Kröger H. Risk factors for early readmission due to surgical complications after treatment of proximal femoral fractures - A Finnish National Database study of 68,800 patients. Injury 2019; 50:403-408. [PMID: 30473368 DOI: 10.1016/j.injury.2018.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/15/2018] [Accepted: 10/27/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hip fracture surgery is associated with a considerable amount medical and surgical complications, which adversely impacts the patient's outcome and/or increases costs. We evaluated what risk factors were associated with the occurrence of early readmission due to surgical complications after hip fracture surgery. MATERIAL AND METHODS A nationwide database with 68,800 hip fracture patients treated between 1999 and 2011 was studied to uncover the association of readmissions with co-morbidities, fracture types, different hospital types and treatment methods using the Cox proportional hazards model. RESULTS Early readmission within three months due to hip fracture surgery complications occurred at a rate of 4.6%. Increased occurrence of readmission was found among patients with: heavy alcoholism (HR 1.38; 95% CI: 1.23-1.53); Parkinson's disease (PD; HR 1.22; 95% CI: 1.05-1.42); pre-existing osteoarthritis (HR 2.02; 95% CI: 1.83-2.23); rheumatic disease (HR 1.44; 95% CI: 1.27-1.65); as well as those with a fracture of the femur neck, depression, presence of a psychotic disorder, an operative delay of at least three days, or previous treatment with total hip arthroplasty. CONCLUSION Our results indicate that there are several factors associated with an increased risk of early readmission. We suggest that in the presence of these factors, the surgical treatment method and postoperative protocol should be carefully planned and performed.
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Affiliation(s)
- Tero T Yli-Kyyny
- Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland.
| | - Reijo Sund
- Centre for Research Methods, Department of Social Research, University of Helsinki, Helsinki, Finland; Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mikko Heinänen
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Antti Malmivaara
- Centre for Health and Social Economics, National Institute for Health and Welfare, Helsinki, Finland; Scientific Unit, Orton Orthopaedic Hospital, Helsinki, Finland
| | - Heikki Kröger
- Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, Finland
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Wiegers EJA, Sewalt CA, Venema E, Schep NWL, Verhaar JAN, Lingsma HF, Den Hartog D. The volume-outcome relationship for hip fractures: a systematic review and meta-analysis of 2,023,469 patients. Acta Orthop 2019; 90:26-32. [PMID: 30712501 PMCID: PMC6366538 DOI: 10.1080/17453674.2018.1545383] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - It has been hypothesized that hospitals and surgeons with high caseloads of hip fracture patients have better outcomes, but empirical studies have reported contradictory results. This systematic review and meta-analysis evaluates the volume-outcome relationship among patients with hip fracture patients. Methods - A search of different databases was performed up to February 2018. Selection of relevant studies, data extraction, and critical appraisal of the methodological quality was performed by 2 independent reviewers. A random-effects meta-analysis using studies with comparative cut-offs was performed to estimate the effect of hospital and surgeon volume on outcome, defined as in-hospital mortality and postoperative complications. Results - 24 studies comprising 2,023,469 patients were included. Overall, the quality was reasonable. 11 studies reported better health outcomes in high-volume centers and 2 studies reported better health outcomes in low-volume centers. In the meta-analysis of 11 studies there was a statistically non-significant association between higher hospital volume and both lower in-hospital mortality (adjusted odds ratio (aOR) 0.87, 95% confidence interval (CI) 0.73-1.04) and fewer postoperative complications (aOR 0.87, CI 0.75-1.02). Four studies on surgeon volume were included in the meta-analysis and showed a minor association between higher surgeon volume and in-hospital mortality (aOR 0.92, CI 0.76-1.12). Interpretation - This systematic review and meta-analysis did not find an evident effect of hospital or surgeon volume on health outcomes. Future research without volume cut-offs is needed to examine whether a true volume-outcome relationship exists.
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Affiliation(s)
- Eveline J A Wiegers
- Department of Public Health, Erasmus University Medical Center, Rotterdam; ,Correspondence:
| | - Charlie A Sewalt
- Department of Public Health, Erasmus University Medical Center, Rotterdam;
| | - Esmee Venema
- Department of Public Health, Erasmus University Medical Center, Rotterdam; ,Department of Neurology, Erasmus University Medical Center, Rotterdam;
| | | | - Jan A N Verhaar
- Department of Orthopaedics, Erasmus University Medical Center, Rotterdam;
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam;
| | - Dennis Den Hartog
- Department of Surgery-Traumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Würdemann FS, Smeeing DPJ, Ferree S, Nawijn F, Verleisdonk EJMM, Leenen LPH, Houwert RM, Hietbrink F. Differentiation in an inclusive trauma system: allocation of lower extremity fractures. World J Emerg Surg 2018; 13:18. [PMID: 29682003 PMCID: PMC5899363 DOI: 10.1186/s13017-018-0178-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 11/26/2022] Open
Abstract
Background Implementation of an inclusive trauma system leads to reduced mortality rates, specifically in polytrauma patients. Field triage is essential in this mortality reduction. Triage systems are developed to identify patients with life-threatening injuries, and trauma mechanisms are important for triaging. Although complex extremity fractures are mostly non-lethal, these injuries are frequently the result of a high-energy trauma mechanism. The aim of this study is to compare injury and patient characteristics, as well as resource demands, of lower extremity fractures between a level (L)1 and level (L)2 trauma centre in a mature inclusive trauma system. Methods This is a retrospective cohort study. Patients with below-the-knee joint fractures diagnosed in a L1 or L2 trauma centre between July 2013 and June 2015 were included. Main outcome parameters were patient demographics, trauma mechanism, fracture pattern, and resource demands. Results One thousand two hundred sixty-seven patients with 1517 lower extremity fractures were included. Most patients were treated in the L2 centre (L1 = 417; L2 = 859). Complex fractures were more frequently triaged to the L1 centre. Patients in the L1 centre had more concomitant injuries to other body regions and ipsi- or contralateral lower extremity. Patients in the L1 centre were more resource demanding: more surgeries (> 1 surgery; 24.9% L1 vs 1.4% L2), higher immediate admission rates (70.1% L1 vs 37.6% L2), and longer length of stay (mean 13.4 days L1 vs 3.1 days L2). Conclusion The majority of patients were treated in the L2 trauma centre, whereas complex lower extremity injuries were mostly treated in the L1 centre, which placed higher demand on resources and labour per patient. This change in allocation is the next step in centralization of low-volume high complex care and high-volume low complex care.
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Affiliation(s)
- F S Würdemann
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands.,3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - D P J Smeeing
- 2Traumacenter, University Medical Center Utrecht, Utrecht, The Netherlands.,3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - S Ferree
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - F Nawijn
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | | | - L P H Leenen
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - R M Houwert
- 2Traumacenter, University Medical Center Utrecht, Utrecht, The Netherlands.,3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - F Hietbrink
- 3Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Abstract
BACKGROUND Large regional hospitals achieve good outcomes for patients with complex conditions. However, recent studies have suggested that some patient groups might not benefit from treatment in higher-level trauma centers. OBJECTIVE To test the hypothesis that older adults with isolated hip fractures experience delayed surgical treatment and worse clinical outcomes when treated in higher-level trauma centers. RESEARCH DESIGN Retrospective cohort study using a statewide longitudinal database that captured 98% of inpatients within California (2007-2011). SUBJECTS All older adults (aged 65 y and above) admitted with an isolated hip fracture who did not require interhospital transfer. MEASURES Days to operation, length of stay, inhospital mortality, 30-day risk of unplanned readmission, 30-day venous thromboembolism, decubitus ulcers, and pneumonia. RESULTS There were 91,401 patients, 6.1% of whom were treated in a level 1 trauma center (L1TC), 17.7% in a level 2 trauma center (L2TC), and 70.2% in a nontrauma center (NTC). Within multivariable logistic and generalized linear regression models, patients treated in L1TCs underwent surgery later (predicted mean difference: 0.30 d; 95% CI, 0.08-0.53), had prolonged inpatient stays (0.99 d, 0.40-1.59), and had higher odds of both 30-day readmission (aOR=1.62; 95% CI, 1.35-1.93) and venous thromboembolism (aOR=1.32, 1.01-1.74) relative to NTCs. There were no differences in mortality, decubitus ulcers, or pneumonias. L2TCs were not different from NTCs across any of the measured outcomes. CONCLUSIONS Older adults with hip fractures may be disadvantaged in L1TCs. Further research should aim to develop our understanding of this disparity to ensure that all patient groups benefit from the resources and expertise available within these hospitals.
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Treskes K, Voeten SC, Tol MCJM, Zuidema WP, Vermeulen J, Goslings JC, Schep NWL, van den Brand JGH, van Velde R, Haverlag R, Ultee JM, Postma VA, Twigt BA, van Dijkman BA, Heres P, Winkelhagen J, Klooster M, Toor A. Trauma surgery by general surgeons: Still an option for proximal femoral fractures? Injury 2017; 48:339-344. [PMID: 27912932 DOI: 10.1016/j.injury.2016.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored. METHODS Patients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were>170/year (high volume), 96-170/year (medium volume) and <96/year (low volume). RESULTS In 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p=0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580-0.958; p=0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995-0.999; p=0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997-1.018; p=0.175). CONCLUSION Surgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.
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Affiliation(s)
- Kaij Treskes
- Trauma Unit, Academic Medical Centre, Amsterdam, Netherlands.
| | - Stijn C Voeten
- Department of traumasurgery, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
| | - Maria C J M Tol
- Trauma Unit, Academic Medical Centre, Amsterdam, Netherlands
| | - Wietse P Zuidema
- Department of traumasurgery, Vrije Universiteit Medical Centre, Amsterdam, Netherlands
| | - Jefrey Vermeulen
- Department of surgery, Spaarne Gasthuis Hospital, Haarlem, Netherlands
| | | | - Niels W L Schep
- Department of surgery, Maasstad hospital, Rotterdam, Netherlands
| | | | | | | | | | | | - Jan M Ultee
- Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, Netherlands
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13
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Gunning AC, Lansink KWW, van Wessem KJP, Balogh ZJ, Rivara FP, Maier RV, Leenen LPH. Demographic Patterns and Outcomes of Patients in Level I Trauma Centers in Three International Trauma Systems. World J Surg 2016; 39:2677-84. [PMID: 26183375 PMCID: PMC4591196 DOI: 10.1007/s00268-015-3162-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction Trauma systems were developed to improve the care for the injured. The designation and elements comprising these systems vary across countries. In this study, we have compared the demographic patterns and patient outcomes of Level I trauma centers in three international trauma systems. Methods International multicenter prospective trauma registry-based study, performed in the University Medical Center Utrecht (UMCU), Utrecht, the Netherlands, John Hunter Hospital (JHH), Newcastle, Australia, and Harborview Medical Center (HMC), Seattle, the United States. Inclusion: patients ≥18 years, admitted in 2012, registered in the institutional trauma registry. Results In UMCU, JHH, and HMC, respectively, 955, 1146, and 4049 patients met the inclusion criteria of which 300, 412, and 1375 patients with Injury Severity Score (ISS) > 15. Mean ISS was higher in JHH (13.5; p < 0.001) and HMC (13.4; p < 0.001) compared to UMCU (11.7). Unadjusted mortality: UMCU = 6.5 %, JHH = 3.6 %, and HMC = 4.8 %. Adjusted odds of death: JHH = 0.498 [95 % confidence interval (CI) 0.303–0.818] and HMC = 0.473 (95 % CI 0.325–0.690) compared to UMCU. HMC compared to JHH was 1.002 (95 % CI 0.664–1.514). Odds of death patients ISS > 15: JHH = 0.507 (95 % CI 0.300–0.857) and HMC = 0.451 (95 % CI 0.297–0.683) compared to UMCU. HMC = 0.931 (95 % CI 0.608–1.425) compared to JHH. TRISS analysis: UMCU: Ws = 0.787, Z = 1.31, M = 0.87; JHH, Ws = 3.583, Z = 6.7, M = 0.89; HMC, Ws = 3.902, Z = 14.6, M = 0.84. Conclusion This study demonstrated substantial differences across centers in patient characteristics and mortality, mainly of neurological cause. Future research must investigate whether the outcome differences remain with nonfatal and long-term outcomes. Furthermore, we must focus on the development of a more valid method to compare systems.
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Affiliation(s)
- Amy C Gunning
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Koen W W Lansink
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn J P van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, Australia
| | - Frederick P Rivara
- Department of Pediatrics, Epidemiology, and Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
| | - Ronald V Maier
- Department of Trauma, Burns and Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Luke P H Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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14
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Metcalfe D, Gabbe BJ, Perry DC, Harris MB, Ekegren CL, Zogg CK, Salim A, Costa ML. Quality of care for patients with a fracture of the hip in major trauma centres. Bone Joint J 2016; 98-B:414-9. [DOI: 10.1302/0301-620x.98b3.36904] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims In this study, we aimed to determine whether designation as a major trauma centre (MTC) affects the quality of care for patients with a fracture of the hip. Patients and Methods All patients in the United Kingdom National Hip Fracture Database, between April 2010 and December 2013, were included. The indicators of quality that were recorded included the time to arrival on an orthopaedic ward, to review by a geriatrician, and to operation. The clinical outcomes were the development of a pressure sore, discharge home, length of stay, in-hospital mortality, and re-operation within 30 days. Results There were 289 466 patients, 49 350 (17%) of whom were treated in hospitals that are now MTCs. Using multivariable logistic and generalised linear regression models, there were no significant differences in any of the indicators of the quality of care or clinical outcomes between MTCs, hospitals awaiting MTC designation and non-MTC hospitals. Conclusion These findings suggest that the regionalisation of major trauma in England did not improve or compromise the overall care of elderly patients with a fracture of the hip. Take home message: There is no evidence that reconfiguring major trauma services in England disrupted the treatment of older adults with a fracture of the hip. Cite this article: Bone Joint J 2016;98-B:414–19.
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Affiliation(s)
| | - B. J. Gabbe
- Monash University, 99
Commercial Road, Melbourne, Vic
3004, Australia
| | - D. C. Perry
- University of Liverpool, Liverpool, L12
2AP, UK
| | - M. B. Harris
- Brigham Women’s Hospital, 75
Francis Street, Boston, MA
02115, USA
| | - C. L. Ekegren
- Monash University, 99
Commercial Road, Melbourne, Vic
3004, Australia
| | - C. K. Zogg
- Harvard Medical School, One
Brigham Circle, Boston, MA
02115, USA
| | - A. Salim
- Harvard Medical School, One
Brigham Circle, Boston, MA
02115, USA
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15
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Metcalfe D, Olufajo O, Rios-Diaz AJ, Haider A, Havens JM, Nitzschke S, Cooper Z, Salim A. Are appendectomy outcomes in level I trauma centers as good as we think? J Surg Res 2016; 202:239-45. [PMID: 27229096 DOI: 10.1016/j.jss.2016.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/07/2016] [Accepted: 01/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND Designated trauma centers improve outcomes for severely injured patients. However, major trauma workload can disrupt other care pathways and some patient groups may compete ineffectively for resources with higher priority trauma cases. This study tested the hypothesis that treatment at a higher-level trauma center is an independent predictor for worse outcome after appendectomy. METHODS An observational study was undertaken using an all-payer longitudinal data set (California State Inpatient Database 2007-2011). All patients with an ICD-90-CM diagnosis of "acute appendicitis" (International Classification of Diseases, Ninth Revision, Clinical Modification code 540) that subsequently underwent appendectomy were included. Patients transferred between hospitals were excluded to minimize selection bias. The outcome measures were days to the operating room, length of stay, unplanned 30-d readmission (to any hospital in California), and in-hospital mortality. Logistic and generalized linear regression models were used to adjust for patient- (age, sex, payer status, race, Charlson comorbidity index, weekend admission, and generalized peritonitis) and hospital-level (teaching status and bed size) factors. RESULTS There were 119,601 patients treated in 278 individual hospitals. Patients in level I trauma centers (L1TCs) reached the operating room later (predicted mean difference 0.25 d [95% confidence interval 0.14-0.36]), stayed in hospital longer (0.83 d [0.36-1.31]), and had higher adjusted odds of generalized peritonitis (odds ratio 1.63 [95% confidence interval 1.13-2.36]) than those in nontrauma centers. There were no differences in mortality or unplanned 30-d readmissions to hospital; or between level II trauma centers and nontrauma centers across any of the measured outcomes. CONCLUSIONS Odds of generalized peritonitis are higher and hospital length of stay is longer in L1TCs, although we found no evidence that patients come to serious harm in such institutions. Further work is necessary to determine whether pressure for resources in L1TCs can explain these findings.
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Affiliation(s)
- David Metcalfe
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts
| | - Olubode Olufajo
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Arturo J Rios-Diaz
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Joaquim M Havens
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Stephanie Nitzschke
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Center for Surgery and Public Health, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts.
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