Variation between Hospitals with Regard to Diagnostic Practice, Coding Accuracy, and Case-Mix. A Retrospective Validation Study of Administrative Data versus Medical Records for Estimating 30-Day Mortality after Hip Fracture

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures

OBJECTIVES

The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation.

METHODS

Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities.

RESULTS

Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism.

CONCLUSION

There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

Does a Code for Acute Myocardial Infarction Mean the Same in All Norwegian Hospitals? A Likelihood Approach to a Medical Record Review

Objective

Health registries are important data sources for epidemiology, quality monitoring, and improvement. Acute myocardial infarction (AMI) is a common, serious condition. Little is known about variation in the positive predictive value (PPV) of a coded AMI diagnosis and its association with hospital quality indicators. The present study aimed to investigate the relationship between PPV and registry-based 30-day mortality after AMI admission and between-hospital variation in PPV.

Study Design and Setting

An electronic record review was performed in a nationwide sample of Norwegian hospitals. Clinical signs and cardiac troponin measurements were abstracted and analyzed using a mixture model for likelihood ratios and parametric bootstrapping.

Results

The overall PPV was estimated to be 97%. We found no statistically significant association between hospital PPV and the classification of hospitals into low, intermediate, and high registry-based 30-day mortality. There was significant variation between hospitals, with a PPV range of 91–100%.

Conclusion

We found no evidence that variation in PPV of AMI diagnosis can explain variation between hospitals in registry-based 30-day mortality after admission. However, PPV varied significantly between hospitals. We were able to use a very efficient statistical approach to the analysis and handling of various sources of uncertainty.

Assessing The Dangers Of A Hospital Stay For Patients With Developmental Disability In England, 2017-19

People with developmental disability have higher health care needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities. We examined the prevalence of five avoidable in-hospital patient safety incidents (adverse drug reactions, hospital-acquired infections, pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis) for four developmental disability groups (people with intellectual disability, chromosomal abnormalities, pervasive developmental disorders, and congenital malformation syndrome) in the English National Health Service during the period April 2017-March 2019. We found that the likelihood of experiencing harm in disability groups was up to 2.7-fold higher than in patients without developmental disability. Patient safety incidents led to an excess length-of-stay in hospital of 3.6-15.4 days and an increased mortality risk of 1.4-15.0 percent. We show persisting quality differences in patients with developmental disability, requiring an explicit national policy focus on the needs of such patients to reduce inequalities, reach parity of care, and lower the burden on health system resources.

Assessment of site-specific X-ray procedure codes for fracture ascertainment: a registry-based cohort study

Site-specific X-ray procedure codes are a useful ancillary source of information for identifying fractures in healthcare administrative and claims data.

INTRODUCTION

Real-world evaluation of fracture epidemiology at the population level from electronic healthcare information, such as administrative data, requires comprehensive data sources and validated case definitions. Only hip fractures are routinely hospitalized, and the identification of most osteoporosis-related fractures which are non-hospitalized fractures remains challenging. Plain X-rays (radiographs) are first-line tests for fracture diagnosis and are frequently repeated to monitor fracture healing, and claims data related to radiologic procedures are available in many healthcare systems. We hypothesized that temporal clustering in plain X-ray procedure codes might be an ancillary source of fracture data.

METHODS

We identified individuals age 40 years and older in Manitoba Bone Mineral Density (BMD) Registry with a fracture diagnosis (hip, forearm, humerus, clinical vertebral) before or following a BMD test. A subset underwent detailed review of X-rays to verify an acute fracture. We examined the association between fracture diagnosis and numbers of site-specific X-ray procedures.

RESULTS

The registry cohort included 7793 individuals with a fracture in the previous 5 years and 8417 incident fractures. The X-ray review cohort included 167 radiologically-verified fractures. The number of site-specific X-ray codes was greater in those with vs without fracture (all P < 0.001). The number of days with site-specific X-rays was strongly associated with a fracture diagnosis (area under the curve 0.90 to 0.99 for all non-vertebral fractures, 0.66 to 0.75 for clinical vertebral fractures). There was good agreement between the date of fracture diagnosis and the first X-ray at all non-vertebral fracture sites (Spearman correlation range 0.65 to 0.99), but this was lower for clinical vertebral fractures (range 0.29 to 0.59).

CONCLUSIONS

Temporal clustering in site-specific X-ray procedures was associated with a corresponding fracture diagnosis in administrative medical records. Non-vertebral fracture sites were more strongly associated with X-ray procedures than clinical vertebral fractures.

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

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 (75^th percentile) proportion of recent surgical admission compared to a low (25^th 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.

Comparison of Epithor clinical national database and medico-administrative database to identify the influence of case-mix on the estimation of hospital outliers

Background

The national Epithor database was initiated in 2003 in France. Fifteen years on, a quality assessment of the recorded data seemed necessary. This study examines the completeness of the data recorded in Epithor through a comparison with the French PMSI database, which is the national medico-administrative reference database. The aim of this study was to demonstrate the influence of data quality with respect to identifying 30-day mortality hospital outliers.

Methods

We used each hospital’s individual FINESS code to compare the number of pulmonary resections and deaths recorded in Epithor to the figures found in the PMSI. Centers were classified into either the good-quality data (GQD) group or the low-quality data (LQD) group. To demonstrate the influence of case-mix quality on the ranking of centers with low-quality data, we used 2 methods to estimate the standardized mortality rate (SMR). For the first (SMR1), the expected number of deaths per hospital was estimated with risk-adjustment models fitted with low-quality data. For the second (SMR2), the expected number of deaths per hospital was estimated with a linear predictor for the LQD group using the coefficients of a logistic regression model developed from the GQD group.

Results

Of the hospitals that use Epithor, 25 were classified in the GQD group and 75 in the LQD group. The 30-day mortality rate was 2.8% (n = 300) in the GQD group vs. 1.9% (n = 181) in the LQD group (P <0.0001). The between-hospital differences in SMR1 appeared substantial (interquartile range (IQR) 0–1.036), and they were even higher in SMR2 (IQR 0–1.19). SMR1 identified 7 hospitals as high-mortality outliers. SMR2 identified 4 hospitals as high-mortality outliers. Some hospitals went from non-outlier to high mortality and vice-versa. Kappa values were roughly 0.46 and indicated moderate agreement.

Conclusion

We found that most hospitals provided Epithor with high-quality data, but other hospitals needed to improve the quality of the information provided. Quality control is essential for this type of database and necessary for the unbiased adjustment of regression models.

Time of admission and mortality after hip fracture: a detailed look at the weekend effect in a nationwide study of 55,211 hip fracture patients in Norway

Background and purpose - There are numerous studies on the weekend effect for hip fracture patients, with conflicting results. We analyzed time of admission and discharge, and the association with mortality and length of hospital stay in more detail. Patients and methods - We used data from 61,211 surgically treated hip fractures in 55,211 patients, admitted to Norwegian hospitals 2008-2014. All patients were aged 50 years or older. Data were analyzed with Cox and Poisson regression. Results - Mortality within 30 days did not differ substantially by day of admission, although admissions on Sundays and holidays had a slightly increased mortality. The hazard ratios were 1.1 (95% confidence interval [CI] 0.97-1.2) for Sundays, and 1.2 (CI 0.98-1.4) for holidays, relative to Mondays. For patients admitted between 6:00 am and 7:00 am the hazard ratio was 1.4 (CI 1.1-1.8) relative to patients admitted between 2:00 pm and 3:00 pm. Discharges during weekends and holidays were associated with a substantial higher mortality than weekday discharges. Patients admitted from Friday to Sunday generally stayed in hospital for a shorter time than patients admitted during other days. Interpretation - Our results indicate that the discussion on weekday versus weekend admission effects might have distracted attention from other important factors, such as time of day of admission, and day of discharge from hospital treatment.