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Ahmed N, Kuo YH. Outcomes of care at higher-level trauma centers in octogenarians with a history of anticoagulant use who fall from ground level. Injury 2023; 54:110718. [PMID: 37127447 DOI: 10.1016/j.injury.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 03/23/2023] [Accepted: 04/09/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND The appropriate care of octogenarian trauma patients after a fall from ground level (FFGL) is a key factor for better outcomes. The purpose of this study is to use data from a national database to evaluate the outcomes of patients who are 80-89 years old with a history of anticoagulant use, sustained a FFGL, and were treated at a higher-level care institution. METHODS The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017-2018 was accessed for the study. All hospitalized trauma patients between the ages of 80-89 years old with a history of anticoagulant use and sustaining an injury after FFGL were included in the study. Other variables included in the study are sex [male], race [white], initial systolic blood pressure (SBP mmHg), Injury Severity Score (ISS), Glasgow Coma Scale (GCS), hypotension with an SBP<110 mmHg and other comorbidities. The outcomes of the patients were compared with the care at higher-level trauma centers (Level I & Level II) and lower-level trauma centers (Level III) using propensity matched analysis. RESULTS After propensity matching, 2348 patients were identified in each group. There was no clinically significant difference between the patients' characteristics who were treated at higher-level and lower-level care centers. A paired matched analysis showed greater mortality in patients who were treated at higher-level care centers compared to lower-level care centers (3.7% vs 2.6%, P = 0.03). The absolute difference in mortality was 1.1%[95% CI: 0.001, 0.022] which may not have any clinical relevance. A greater number of patients were discharged to home and a lesser number of patients were discharged to a skilled nursing facility (SNF) when they were treated at higher-level trauma centers. CONCLUSION & RELEVANCE The care at higher-level trauma centers did not show any benefit in-hospital mortality in the short term. A higher number of patients was discharged to home without assistance.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA; Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Yen-Hong Kuo
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, USA; Hackensack Meridian School of Medicine, Nutley, NJ, USA
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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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Matthews L, Kelly E, Fleming A, Byerly S, Fischer P, Molyneaux I, Kerwin A, Howley I. An Analysis of Injured Patients Treated at Level 1 Trauma Centers Versus Other Centers: A Scoping Review. J Surg Res 2023; 284:70-93. [PMID: 36549038 DOI: 10.1016/j.jss.2022.11.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Trauma systems continue to evolve to create the best outcomes possible for patients who have undergone traumatic injury. OBJECTIVE This review aims to evaluate the existing research on outcomes based on field triage to a Level 1 trauma center (L1TC) compared to other levels of hospitals and nontrauma centers. METHODS A structured literature search was conducted using PubMed, CINAHL, Embase, and the Cochrane Database. Studies analyzing measures of morbidity, mortality, and cost after receiving care at L1TCs compared to lower-level trauma centers and nontrauma centers in the United States and Canada were included. Three independent reviewers reviewed abstracts, and two independent reviewers conducted full-text review and quality assessment of the included articles. RESULTS Twelve thousand five hundred fourteen unique articles were identified using the literature search. 61 relevant studies were included in this scoping review. 95.2% of included studies were national or regional studies, and 96.8% were registry-based studies. 72.6% of included studies adjusted their results to account for injury severity. The findings from receiving trauma care at L1TCs vary depending on severity of injury, type of injury sustained, and patient characteristics. Existing literature suffers from limitations inherent to large de-identified databases, making record linkage between hospitals impossible. CONCLUSIONS This scoping review shows that the survival benefit of L1TC care is largest for patients with the most severe injuries. This scoping review demonstrates that further research using high-quality data is needed to elucidate more about how to structure trauma systems to improve outcomes for patients with different severities of injuries and in different types of facilities.
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Affiliation(s)
- Lynley Matthews
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Emma Kelly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew Fleming
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Peter Fischer
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ian Molyneaux
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrew Kerwin
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Isaac Howley
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
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Nilsen SM, Asheim A, Carlsen F, Anthun KS, Johnsen LG, Vatten LJ, Bjørngaard JH. High volumes of recent surgical admissions, time to surgery, and 60-day mortality. Bone Joint J 2021; 103-B:264-270. [PMID: 33517718 PMCID: PMC7954185 DOI: 10.1302/0301-620x.103b2.bjj-2020-1581.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. METHODS This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. RESULTS Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). CONCLUSION A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264-270.
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Affiliation(s)
- Sara Marie Nilsen
- Center for Health Care Improvement, St. Olav's Hospital HF, Trondheim University Hospital, Trondheim, Norway
| | - Andreas Asheim
- Center for Health Care Improvement, St. Olav's Hospital HF, Trondheim University Hospital, Trondheim, Norway.,Department of Mathematical Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjartan Sarheim Anthun
- Department of Health Research, SINTEF Digital, Trondheim, Norway.,Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lars Gunnar Johnsen
- Department of Orthopaedic Surgery, St. Olav's Hospital HF, Trondheim, Norway.,Department of Neuromedicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Lars Johan Vatten
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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Rogers FB, Morgan ME, Brown CT, Vernon TM, Bresz KE, Cook AD, Malat J, Sohail N, Bradburn EH. Geriatric Trauma Mortality: Does Trauma Center Level Matter? Am Surg 2020; 87:1965-1971. [PMID: 33382347 DOI: 10.1177/0003134820983190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Given their mostly rural/suburban locations, level II trauma centers (TCs) may offer greater exposure to and experience in managing geriatric trauma patients. We hypothesized that geriatric patients would have improved outcomes at level II TCs compared to level I TCs. METHODS The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003 to 2017 for geriatric (age ≥65 years) trauma patients admitted to level I and II TCs in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in care between level I and II TCs. A multivariate logistic regression model assessed the adjusted impact of care at level I vs II TCs on mortality, complications, and functional status at discharge (FSD). The National Trauma Data Bank (NTDB) was retrospectively queried for geriatric (age ≥65 years) trauma admissions to state-accredited level I or level II TCs in 2013. RESULTS 112 648 patients met inclusion criteria. The proportion of geriatric trauma patients across level I and level II TCs were determined to be 29.1% and 36.2% (P <.001), respectively. In adjusted analysis, there was no difference in mortality (adjusted odds ratio [AOR]: 1.13; P = .375), complications (AOR: 1.25; P = .080) or FSD (AOR: 1.09; P = .493) when comparing level I to level II TCs. Adjusted analysis from the NTDB (n = 144 622) also found that mortality was not associated with TC level (AOR: 1.04; P = .182). DISCUSSION Level I and level II TCs had similar rates of mortality, complications, and functional outcomes despite a higher proportion (but lower absolute number) of geriatric patients being admitted to level II TCs. Future consideration for location of centers of excellence in geriatric trauma should include both level I and II TCs.
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Affiliation(s)
- Frederick B Rogers
- Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Madison E Morgan
- Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Catherine Ting Brown
- Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Tawnya M Vernon
- Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Kellie E Bresz
- Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Alan D Cook
- 12347University of Texas Health Science Center at Tyler, UT Health East Texas, Tyler, TX, USA
| | - Jaclyn Malat
- 6556Pennsylvania College of Osteopathic Medicine Surgical Residency Program, Philadelphia, PA, USA
| | - Neelofer Sohail
- Geriatric Specialists, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | - Eric H Bradburn
- Trauma and Acute Care Surgery, 209639Penn Medicine Lancaster General Health, Lancaster, PA, USA
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Abstract
BACKGROUND Traditional care of patients with geriatric hip fracture has been fragmented with patients admitted under various specialty services and to different units within a hospital. This produces inconsistent care and leads to varying outcomes that can be associated with increased length of stay, delays in time from admission to surgery, and higher readmission rates. PURPOSE The purpose of this article is to describe the process taken to establish a successful geriatric hip fracture program (GFP) and the initial results observed in a single institution after its implementation. METHODS All patients 60 years or older, with an osteoporotic hip fracture sustained from a low energy mechanism (defined as a fall from 3-ft height or less), were included in our program. Fracture patterns include femoral neck, intertrochanteric, pertrochanteric, and subtrochanteric femur fractures including displaced, nondisplaced, and periprosthetic fractures. Preprogram data included all patients admitted from January 1, 2012, through December 31, 2014; postprogram data were collected on patients admitted between May 1, 2016, and May 1, 2018. RESULTS Demographic characteristics of the populations were similar. After the GFP was implemented, the proportion of patients who were treated surgically within 24 and 48 hours increased. The average number of hours between admission and surgery significantly reduced from 35.2 to 23.2 hours. Overall length of stay was decreased by 1.8 days and readmission within 30 days of discharge was lower. Reasons for readmission were similar in both timeframes. The rate of inpatient death was similar in the two groups. Mortality within 30 days of surgery appeared somewhat higher in the post-GFP period. CONCLUSION Our program found that, with the utilization of a multidisciplinary approach, we could positively influence the care of patients with geriatric hip fracture through the implementation of evidence-based practice guidelines. In the first 2 years after initiation of the GFP, our institution saw a decrease in time from admission to surgery, length of stay, and blood transfusion requirements.
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Pasternack JB, Ciminero ML, Silver M, Chang J, Gupta P, Kang KK. Does Care at a Trauma Center Affect Geriatric Hip Fracture Patients? Geriatr Orthop Surg Rehabil 2020; 11:2151459320911865. [PMID: 32206383 PMCID: PMC7076573 DOI: 10.1177/2151459320911865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/10/2019] [Accepted: 01/22/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction: With respect to care setting, there are mixed results in the literature with respect to the role of trauma centers in management of isolated geriatric hip fractures. During a transition from a Level 3 to a Level 1 trauma center, significant protocol changes were implemented that sought to standardize and improve the care of hip fracture patients. The objective of this study was to determine the effects of this transition on the management, efficiency, morbidity, mortality, and discharge of geriatric hip fracture patients. Methods: A retrospective chart review of geriatric hip fractures treated operatively was conducted. Two cohorts were compared: hip fractures in the year prior to (2015) and year following (2017) Level 1 Trauma designation. Primary outcome measures were length of stay (LOS), transfusion rate, complication rate, and mortality rate. Secondary outcome measures were time from emergency department (ED) arrival to medical optimization, time from medical optimization to surgery, time from ED arrival to surgery, and discharge destination. Results: There were no differences in LOS, transfusion rate, or complication rate between the two cohorts. There was a nonsignificant trend toward lower in-hospital mortality after the transition (2.24% vs 0.83%). There were no differences in time from ED arrival to medical optimization, time from medical optimization to surgery, time from ED arrival to surgery, and percentage of patients discharged home between the cohorts. Discussion: Management of operative geriatric hip fractures at our institution has remained consistent following transition to a Level 1 trauma center. There was a trend toward lower mortality after transition, but this difference was not statistically significant. We attribute the variety of findings in the literature with respect to trauma center management of hip fractures to individualized institutional trauma protocols as well as the diverse patient populations these centers serve.
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Affiliation(s)
- Jordan B Pasternack
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Matthew L Ciminero
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Michael Silver
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Joseph Chang
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Piyush Gupta
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Kevin K Kang
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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Evaluating the outcomes of blunt thoracic trauma in elderly patients following a fall from a ground level: higher level care institution vs. lower level care institution. Eur J Trauma Emerg Surg 2019; 47:955-963. [PMID: 31583421 DOI: 10.1007/s00068-019-01230-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/03/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of the study is to evaluate the outcomes of higher level care institutions of elderly patients who sustained a thoracic injury after a ground-level fall (GLF). HYPOTHESIS Higher level care institutions have a better survival. METHODS The National Trauma Data Bank (NTDB) data set of 2012-2014 was accessed for the study. All patients, 65 years of age and older, who experienced a GLF and sustained a thoracic injury, were included in the study. Patient demography, injury characteristics including injury severity score (ISS), Glasgow coma scale (GCS) motor score, comorbidities, and patient outcomes were compared between the higher level care institution [American College of Surgeon (ACS) level I and level II trauma centers) and lower level care institution (ACS level III and level IV and unranked-trauma centers). On univariate analysis, some significant patient characteristic differences were found; therefore, propensity score matching and paired analyses were performed. All P values are two sided, and a P value < 0.05 was considered statistically significant. RESULTS Out of the 15,256 patients who satisfied the inclusion criteria, approximately 52% (7994) of patients were treated at a higher level care institution. On univariate analysis, significant differences were found between the lower level care institution and higher level care institution regarding male gender (44.2% vs.46%, P = 0.03), ISS median [interquartile] (9 [5-12] vs. 9 [5-13], P < 0.001), history of alcohol abuse (4.2% vs. 5.3%, P = 0.007), dementia (8.7% vs. 9.8%, P = 0.02), bleeding disorder or history of anticoagulation use (17% vs. 18.4%, P = 0.03), obesity (5% vs. 6.6%, P < 0.001), and abbreviated injury scale (AIS) thorax (2 [1-3] vs. 3 [2-3], P < 0.001). After propensity score matching, the majority of the characteristics were balanced with few exceptions, including ISS, AIS ≥ 3 head and abdomen, and P values < 0.05. The overall in-hospital mortality was not significantly different between the higher level care institution vs. the lower level care institution (4.4% vs. 3.9%, P = 0.14). The median hospital length of stay and 95% confidence interval between both groups was (5 [5, 5] and 5 [5, 5], P = 0.72). CONCLUSION Treating elderly patients with blunt chest trauma in higher level care institutions failed to show any benefit in overall survival or hospital length of stay. LEVEL OF EVIDENCE IV. STUDY TYPE Observational cohort.
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Sobolev B, Guy P, Sheehan KJ, Kuramoto L, Sutherland JM, Levy AR, Blair JA, Bohm E, Kim JD, Harvey EJ, Morin SN, Beaupre L, Dunbar M, Jaglal S, Waddell J. Mortality effects of timing alternatives for hip fracture surgery. CMAJ 2019; 190:E923-E932. [PMID: 30087128 DOI: 10.1503/cmaj.171512] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay. METHODS We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram. RESULTS Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%). INTERPRETATION Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.
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Affiliation(s)
- Boris Sobolev
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont.
| | - Pierre Guy
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Katie Jane Sheehan
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Lisa Kuramoto
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Jason M Sutherland
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Adrian R Levy
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - James A Blair
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Eric Bohm
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Jason D Kim
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Edward J Harvey
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Suzanne N Morin
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Lauren Beaupre
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Michael Dunbar
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - Susan Jaglal
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
| | - James Waddell
- School of Population and Public Health (Sobolev, Sutherland, Kim) and Centre for Hip Health and Mobility (Guy), The University of British Columbia, Vancouver, BC; Department of Population Health Sciences (Sheehan), School of Population Health and Environmental Sciences, King's College London, London, UK; Vancouver Coastal Health Research Institute (Kuramoto), Vancouver, BC; Department of Community Health and Epidemiology (Levy), Dalhousie University, Halifax, NS; Department of Orthopaedics and Rehabilitation (Blair), William Beaumont Army Medical Center, El Paso, Tex.; Section of Orthopaedic Surgery and George and Fay Yee Centre for Healthcare Innovation (Bohm), University of Manitoba, Winnipeg, Man.; Division of Orthopaedic Surgery (Harvey) and Department of Medicine (Morin), McGill University, Montréal, Que.; Departments of Physical Therapy and Division of Orthopaedic Surgery (Beaupre), University of Alberta, Edmonton, Alta.; Division of Orthopaedic Surgery (Dunbar), Dalhousie University, Halifax, NS; Department of Physical Therapy (Jaglal) and Division of Orthopaedic Surgery (Waddell), University of Toronto, Toronto, Ont
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10
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Metcalfe D, Costa ML, Parsons NR, Achten J, Masters J, Png ME, Lamb SE, Griffin XL. Validation of a prospective cohort study of older adults with hip fractures. Bone Joint J 2019; 101-B:708-714. [DOI: 10.1302/0301-620x.101b6.bjj-2018-1623.r1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims This study sought to determine the proportion of older adults with hip fractures captured by a multicentre prospective cohort, the World Hip Trauma Evaluation (WHiTE), whether there was evidence of selection bias during WHiTE recruitment, and the extent to which the WHiTE cohort is representative of the broader population of older adults with hip fractures. Patients and Methods The characteristics of patients recruited into the WHiTE cohort study were compared with those treated at WHiTE hospitals during the same timeframe and submitted to the National Hip Fracture Database (NHFD). Results Patients recruited to WHiTE were more likely to be admitted from their own home (83.5% vs 80.2%; p < 0.001) and to have a higher median Abbreviated Mental Test Score (AMTS) (9 (interquartile range (IQR) 6 to 10) vs 9 (IQR 5 to 10); p < 0.001) than those who were not recruited. In terms of WHiTE cohort generalizability, participating hospitals included a greater proportion of Major Trauma Centres (47.8% vs 7.8%) and large hospitals (997 (IQR 873 to 1290) vs 707 (459 to 903) beds) with high-volume Emergency Departments (median annual attendances of 43 981 (IQR 37 147 to 54 385) vs 35 964 (IQR 26 229 to 50 551)). However, there were few differences in baseline characteristics between patients in the WHiTE cohort and those recorded in the NHFD. Conclusion There is evidence of a weak selection bias towards recruiting fitter patients within the WHiTE cohort, which will help to put into context the findings of future studies. We conclude that the patients within the WHiTE cohort are representative of the national population of older adults with hip fractures throughout England, Wales, and Northern Ireland. Cite this article: Bone Joint J 2019;101-B:708–714.
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Affiliation(s)
- D. Metcalfe
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - M. L. Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - N. R. Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - J. Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - J. Masters
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - M. E. Png
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - S. E. Lamb
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - X. L. Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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11
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Newgard CD, Lin A, Yanez ND, Bulger E, Malveau S, Caughey A, McConnell KJ, Zive D, Griffiths D, Mirlohi R, Eckstrom E. Long-term outcomes among injured older adults transported by emergency medical services. Injury 2019; 50:1175-1185. [PMID: 31101411 DOI: 10.1016/j.injury.2019.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION/OBJECTIVE Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS). MATERIALS AND METHODS This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR). RESULTS 15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p < .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p = .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates. CONCLUSIONS Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury.
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Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States.
| | - Amber Lin
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - N David Yanez
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States; School of Public Health, Oregon Health & Science University, Portland, Oregon, United States
| | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Susan Malveau
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Aaron Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, United States
| | - K John McConnell
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States; Center for Health Systems Effectiveness, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Dana Zive
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Denise Griffiths
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Rahill Mirlohi
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Elizabeth Eckstrom
- Department of Internal Medicine, Division of Geriatrics, Oregon Health & Science University, Portland, Oregon, United States
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12
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Vuagnat A, Yilmaz E, Roussot A, Rodwin V, Gadreau M, Bernard A, Creuzot-Garcher C, Quantin C. Did case-based payment influence surgical readmission rates in France? A retrospective study. BMJ Open 2018; 8:e018164. [PMID: 29391376 PMCID: PMC5829593 DOI: 10.1136/bmjopen-2017-018164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To determine whether implementation of a case-based payment system changed all-cause readmission rates in the 30 days following discharge after surgery, we analysed all surgical procedures performed in all hospitals in France before (2002-2004), during (2005-2008) and after (2009-2012) its implementation. SETTING Our study is based on claims data for all surgical procedures performed in all acute care hospitals with >300 surgical admissions per year (740 hospitals) in France over 11 years (2002-2012; n=51.6 million admissions). INTERVENTIONS We analysed all-cause 30-day readmission rates after surgery using a logistic regression model and an interrupted time series analysis. RESULTS The overall 30-day all-cause readmission rate following discharge after surgery increased from 8.8% to 10.0% (P<0.001) for the public sector and from 5.9% to 8.6% (P<0.001) for the private sector. Interrupted time series models revealed a significant linear increase in readmission rates over the study period in all types of hospitals. However, the implementation of case-based payment was only associated with a significant increase in rehospitalisation rates for private hospitals (P<0.001). CONCLUSION In France, the increase in the readmission rate appears to be relatively steady in both the private and public sector but appears not to have been affected by the introduction of a case-based payment system after accounting for changes in care practices in the public sector.
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Affiliation(s)
- Albert Vuagnat
- Department of Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
- Division of Research and Statistics, Ministry of Health, Paris, France
| | - Engin Yilmaz
- Division of Research and Statistics, Ministry of Health, Paris, France
- School of Economics, University of Sorbonne, Paris, France
| | - Adrien Roussot
- Department of Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
| | - Victor Rodwin
- The Robert F. Wagner School of Public Service, New York University, New York, USA
| | - Maryse Gadreau
- Laboratoire d’Economie de Dijon, Université Bourgogne/Franche-Comté, Inserm U1200, CNRS UMR 6307, Dijon, France
| | - Alain Bernard
- Department of Thoracic Surgery, University Hospital, Dijon, France
| | - Catherine Creuzot-Garcher
- Department of Ophthalmology, University Hospital, Dijon, France
- Eye and Nutrition Research Group, Bourgogne Franche-Comté University, Dijon, France
| | - Catherine Quantin
- Department of Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France
- Clinical Investigation Center, Dijon University Hospital, Dijon, France
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, Paris, France
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13
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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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14
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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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15
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Rios-Diaz AJ, Olufajo OA, Stinebring J, Endicott S, McKown BT, Metcalfe D, Zogg CK, Salim A. Hospital characteristics associated with increased conversion rates among organ donors in New England. Am J Surg 2017; 214:757-761. [PMID: 28390648 DOI: 10.1016/j.amjsurg.2017.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 03/01/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND It is unknown whether hospital characteristics affect institutional performance with regard to organ donation. We sought to determine which hospital- and patient-level characteristics are associated with high organ donor conversion rates after brain death (DBD). METHODS Data were extracted from the regional Organ Procurement Organization (2011-2014) and other sources. Hospitals were stratified into high-conversion hospitals (HCH; upper-tertile) and low-conversion hospitals (LCH; lower-tertile) according to conversion rates. Hospital- and patient-characteristics were compared between groups. RESULTS There were 564 potential DBD donors in 27 hospitals. Conversion rates differed between hospitals in different states (p < 0.001). HCH were more likely to be small (median bed size 194 vs. 337; p = 0.024), non-teaching hospitals (40% vs. 88%; p = 0.025), non-trauma center (30% vs. 77%; p = 0.040). Potential donors differed between HCH and LCH in race (p < 0.01) and mechanism of injury/disease process (p < 0.01). CONCLUSION There is significant variation between hospitals in terms of organ donor conversion rates. This suggests that there is a pool of potential donors in large specialized hospitals that are not successfully converted to DBD.
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Affiliation(s)
- Arturo J Rios-Diaz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Olubode A Olufajo
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA, USA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School Brigham, Boston, MA, USA
| | | | | | | | - David Metcalfe
- Kadoorie Centre for Critical Care Research, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ali Salim
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School Brigham, Boston, MA, USA
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16
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Rios-Diaz AJ, Metcalfe D, Olufajo OA, Zogg CK, Yorkgitis B, Singh M, Haider AH, Salim A. Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need? J Am Coll Surg 2016; 223:764-773.e2. [PMID: 28193322 DOI: 10.1016/j.jamcollsurg.2016.08.569] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/30/2016] [Accepted: 08/31/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality. STUDY DESIGN We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates. RESULTS There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year. CONCLUSIONS There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients.
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Affiliation(s)
- Arturo J Rios-Diaz
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA.
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Olubode A Olufajo
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
| | - Cheryl K Zogg
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
| | - Brian Yorkgitis
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mansher Singh
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
| | - Ali Salim
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA
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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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