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Hollister L, Girardot K, Konger J, Zhu TH. Factors Influencing Time to Definitive Care in Hip Fracture Patients in a Rural Health System. J Trauma Nurs 2024; 31:182-188. [PMID: 38990873 DOI: 10.1097/jtn.0000000000000796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
BACKGROUND Current literature has not adequately addressed factors affecting wait times for hip fracture surgery in the rural setting. OBJECTIVE This study aims to assess the factors affecting admission, transit, and preoperative wait times that impact the timeliness of hip fracture surgery within a rural health system. METHODS A single-center retrospective cross-sectional study was conducted in a rural community comprising five community hospitals and two receiving hospitals. A trauma registry study included all hip fracture cases from 2019. Mean, standard deviation, median, and interquartile range were calculated for admission wait times, transit times to the receiving hospitals, and preoperative wait times in hours. Metrics based on means or medians were developed for these wait times. RESULTS A total of 163 patients met the inclusion criteria. The emergency department wait times before and after admission to the community hospitals were 1 hour and 2.5 hours, respectively. The transit times from the community hospitals, ranging from shorter to farther distances, to receiving hospitals were 40 minutes and 1 hour, respectively. The preoperative wait time for admitted and transferred patients was 12 hours. CONCLUSION Our study outlines a methodology for establishing wait time metrics that impact surgical timeliness for hip fracture patients within a rural healthcare system. We recommend conducting comparable studies with larger sample sizes across different healthcare systems.
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Affiliation(s)
- Lisa Hollister
- Author Affiliation: Trauma Services, Parkview Adult and Pediatric Level 2 Trauma Center, Fort Wayne, Indiana
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2
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Chui J, Hegazy AF, German M, Arango-Ferreira C, Fochesato LA, Lavi R, Bainbridge D. Point-of-care lung and cardiac ultrasound (LUCAS) study in hip fracture patients: a prospective cohort study. Can J Anaesth 2023; 70:1474-1485. [PMID: 37344745 DOI: 10.1007/s12630-023-02511-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/28/2023] [Accepted: 01/30/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE A clinical conflict often presented with hip fracture patients is whether to proceed with timely surgery or delay surgery until a formal echocardiogram is conducted. This study aimed to assess the impact of incorporating point-of-care lung and cardiac ultrasound (LUCAS) scans as part of the preoperative assessment for hip fracture patients. METHODS We recruited 225 consecutive adult patients booked for urgent hip arthroplasty surgery. A LUCAS scan was performed for each patient. The anesthesiologists were asked to provide their anesthetic plans before and after acknowledging the results of the LUCAS scans. The primary endpoint was a composite outcome of changes to the anesthetic plan. The secondary outcomes included anesthesiologists' opinions of the LUCAS scans. RESULTS One-hundred-ninety-eight patients were included. The majority of LUCAS findings were not severe. A common abnormal finding was hypovolemia (31%). One-hundred-and-six anesthetic management decisions were changed, with 59 of these changes being an escalation of the anesthetic plan, and 47 of these changes being a de-escalation. Eighty-three percent of anesthesiologists agreed that LUCAS affirmed their anesthetic plans and should be an integral part of the perioperative assessment. CONCLUSION This study found that LUCAS scans did not significantly alter the anesthetic plan for hip fracture patients. Nevertheless, LUCAS scans can rule out severe cardiopulmonary conditions and allow for both escalation and de-escalation of care. In the setting of early hip surgery, LUCAS presents a viable option in selected patients to address the unmet need to allow for both timely surgery and comprehensive patient evaluation. STUDY REGISTRATION ClinicalTrials.gov (NCT03275129); registered 8 July 2018.
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Affiliation(s)
- Jason Chui
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Ahmed F Hegazy
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Mark German
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Camila Arango-Ferreira
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Lee-Anne Fochesato
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Ronit Lavi
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Daniel Bainbridge
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine and Dentistry, University of Western Ontario, C3-106, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
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Merchán-Galvis AM, Muñoz-García DA, Solano F, Velásquez JC, Sotelo NF, Molina DA, Caicedo JP, Concha JM, Calvache JA, Martínez-Zapata MJ. Delayed surgery and health related quality of life in patients with proximal femoral fracture. Sci Rep 2023; 13:11131. [PMID: 37429947 DOI: 10.1038/s41598-023-33592-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 04/15/2023] [Indexed: 07/12/2023] Open
Abstract
This study aimed to establish factors associated with delayed surgery in patients with proximal femoral fracture and to assess patients' health-related quality of life (HRQoL) after surgery including all-cause 6-months mortality. This was a single-center, observational, prospective cohort study that included patients with a proximal femur fracture. We described patients' HRQoL measured by EuroQoL (EQ-5D-5L and EQ-VAS) questionnaire and perioperative complications (including mortality) 6 months after surgery. We included 163 patients with a mean age of 80.5 years, the majority were women and 76.1% reported falling from their own height. The mean time between hospital admission and surgery was 8.3 days (SD 4.9 days) and the mean hospital stay was 13.5 days (SD 10.4 days). After adjustment, the principal factor associated with delayed surgery was adjournment in surgery authorization (3.7 days). EQ-5D-5L index values and the VAS score at 1 month after surgery were 0.489 and 61.1, at 3 months were 0.613 and 65.8, and at 6 months 0.662 and 66.7 respectively. Mortality at 6 months of follow-up was 11% (18 patients). In conclusion, administrative authorization was the strongest associated factor with delayed time from hospital admission to surgery. HRQoL of patients with a proximal femoral fracture improved 6 months after surgery.Trial registration: NCT04217642.
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Affiliation(s)
- Angela María Merchán-Galvis
- Iberoamerican Cochrane Centre-Public Health and Clinical Epidemiology, IIBSant Pau, Barcelona, Spain.
- Department of Social Medicine and Family Health, Universidad del Cauca, Popayán, Colombia.
| | | | - Felipe Solano
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
| | | | | | | | | | - Juan Manuel Concha
- Department of Surgical Sciences, Universidad del Cauca, Popayán, Colombia
| | - José Andrés Calvache
- Department of Anaesthesiology, Universidad del Cauca, Popayán, Colombia
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - María José Martínez-Zapata
- Iberoamerican Cochrane Centre-Public Health and Clinical Epidemiology, IIBSant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER of Epidemiology and Public Health), Madrid, Spain
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Merchán-Galvis A, Anaya R, Rodriguez M, Llorca J, Castejón M, Gil JM, Millan A, Estepa V, Cardona E, Garcia-Sanchez Y, Ruiz A, Martinez-Zapata MJ. Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery. J Clin Med 2023; 12:1130. [PMID: 36769778 PMCID: PMC9918231 DOI: 10.3390/jcm12031130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/25/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL). METHODS Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months. RESULTS From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes. CONCLUSION It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.
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Affiliation(s)
- Angela Merchán-Galvis
- Public Health and Clinical Epidemiology Service—Iberoamerican Cochrane Centre, IIB Sant Pau, 08025 Barcelona, Spain
- Department of Social Medicine and Family Health, Universidad del Cauca, Popayan 190003, Colombia
| | - Rafael Anaya
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Mireia Rodriguez
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Jordi Llorca
- Anesthesiology Service, Xarxa Assitencial Universitària de Manresa, 08243 Barcelona, Spain
| | - Mercé Castejón
- Anesthesiology Service, Xarxa Assitencial Universitària de Manresa, 08243 Barcelona, Spain
| | - José María Gil
- Anesthesiology Service, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Angélica Millan
- Orthopedic and Traumatology Surgery Service, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Verónica Estepa
- Anesthesiology Service, Hospital de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Elena Cardona
- Anesthesiology Service, Hospital de la Vall d’Hebron, 08035 Barcelona, Spain
| | - Yaiza Garcia-Sanchez
- Orthopedic and Traumatology Surgery Service, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Ana Ruiz
- Anesthesiology Service, Hospital Clinic de Barcelona, 08036 Barcelona, Spain
| | - Maria Jose Martinez-Zapata
- Public Health and Clinical Epidemiology Service—Iberoamerican Cochrane Centre, IIB Sant Pau, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER of Epidemiology and Public Health), 28029 Madrid, Spain
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Castellanos SC, Marco FL, Domínguez EB, Gálvez EMV, Pérez BM. Does delaying surgery for "healthy" hip fracture patients have increased complications and mortality? Injury 2022; 53:3209-3213. [PMID: 35842349 DOI: 10.1016/j.injury.2022.06.035] [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: 05/18/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical delay is one of the risk factors for mortality and morbidity in patients with HF. One of the causes of delay is due to admission on Thursday-Friday, weekends, holidays or previous periods. The final objective of this study is to analyze administrative-organizational delay in complication and mortality rates. MATERIAL AND METHODS A total of 607 cases of surgically operated hip fractures were analyzed. Two groups were established, one of them operated on in < 48 h (ND group) and the other surgically delayed for administrative organizational reasons (AA group). Demographic variables related to treatment and fracture were analyzed in both groups, as well as the rates of surgical wound complications, general complications and mortality rate in the first 30 days, in the first year and more than one year after surgery. RESULTS We observed a surgical wound seroma and staining rate of 15.7% in the AA group and 9.6% in the ND group; and a surgical wound surface infection rate of 1.9% in the AA group and 0.8% in the ND group (p = 0.275). General complications occurred in 34.4% (AA group) and 29% (ND group). The 30-day mortality rate was 4.8% in the AA group and 1.9% in the ND group (p = 0.081). CONCLUSION We found no statistically significant differences in patients delayed for administrative reasons in terms of mortality and surgical wound and general complication rates. Although the proportion of surgical wound complications and 30-day mortality was higher in the AA group versus the ND group.
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Siow WS, Tay L, Mah CL. Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients. BMJ Open Qual 2022; 11:bmjoq-2021-001738. [PMID: 35940697 PMCID: PMC9364401 DOI: 10.1136/bmjoq-2021-001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 07/24/2022] [Indexed: 11/04/2022] Open
Abstract
BackgroundSurgery is recommended within 48 hours of hip fractures for better perioperative outcomes. Yet, such targets still commonly remain a challenge. Our institution is no exception.As part of a hospital-wide initiative, our anaesthesia department focused on improving perioperative processes with aims to reduce the time to first anaesthesia consult and surgery for hip fracture patients. Acknowledging multiple causes for surgical delay, we decided first to address anaesthesia-specific factors—(a) first anaesthetist contact usually happens after surgery is offered which leaves a short runway for preoptimisation, (b) this is compounded by varying degrees of anaesthetist involvement for follow-up thereafter. (c) There is a need to calibrate our perioperative care standards and (d) enforce more consistent auditing in quality assurance. This project was conducted in a 1000-bed hospital serving eastern Singapore.InterventionWe created an integrated anaesthesia consultant-led outreach service for hip fracture patients, based on a perioperative workflow system to provide proactive anaesthetist consults within 24 hours of admission in advance of surgical decision. This was streamlined with a coordinated follow-up system for preoptimisation until surgery.MethodsOur quality improvement project applied the iterative Plan-Do-Study-Act model from pilot to sustainability stage. We collected data at baseline followed by 6-monthly audits from electronic databases.Primary outcomes measured were time to first anaesthesia consult and surgery. Secondary outcomes included rate of critical care reviews and admission, mortality rate, length of stay and time to nerve blocks.ResultsPost implementation, our service reviewed >600 hip fracture patients. Median time to anaesthesia consult reduced significantly from 35.3 hours (2019) to 21.5 hours (2021) (p=0.029). Median time to surgery was reduced from 61.5 hours (2019) to 50 hours (2021) (p=0.897) with a 13.6% increase in patients operated <48 hours. Critical care admissions, 6-monthly and 12-monthly mortality rates and time to nerve block were reduced with a greater percentage of patients discharged within 10 days.ConclusionOur project focused on improving anaesthesia perioperative processes to address surgical delays in hip fracture patients. Our consultant-led anaesthesia service ensured that proactive anaesthesia care was delivered to provide sufficient time for preoptimisation with greater standardisation to follow-up, better communication and quality assurance.
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Affiliation(s)
- Wei Shyan Siow
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Leeanna Tay
- ValueCare Programme Office, Centre of Performance Excellence, Changi General Hospital, Singapore
| | - Chou Liang Mah
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
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Law TJ, Stephens D, Wright JG. Surgical wait times and socioeconomic status in a public healthcare system: a retrospective analysis. BMC Health Serv Res 2022; 22:579. [PMID: 35488331 PMCID: PMC9051767 DOI: 10.1186/s12913-022-07976-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/18/2022] [Indexed: 11/27/2022] Open
Abstract
Background One aim of publicly-funded health care systems is to provide equitable access to care irrespective of ability to pay. At the same time, differences in socioeconomic status (SES) are associated with health outcomes and access to care, including waiting times for surgery. In public systems where both high- and low-SES patients use the same resources, low-SES patients may be adversely impacted in surgical waiting times. The purpose of this study was to determine whether a publicly-funded health system can provide equitable access to surgical care across socioeconomic status. Methods Patient-level records were obtained from a comprehensive provincially-administered surgical wait time database, encompassing years 2006–2015 and 98% of Ontario hospitals. Patient SES was determined by linking postal code with the Material and Social Deprivation Index. Surgical waiting times (time in days between decision to treat and surgery) accounted for patient-initiated delays in treatment, and regression analysis considered age, SES, rurality, sex, priority level for surgical urgency (assigned by surgeons), surgical subspecialty, number of visits, and procedure year. Results For the 4,253,305 surgical episodes, the mean wait time was 62.3 (SD 75.4) days. Repeated measures least squares regression analysis showed the least deprived SES quintile waited 3 days longer than the most deprived quintile. Wait times dropped in the initial study period but then increased. The proportion of procedures exceeding wait time access targets remained low at 11–13%. Conclusions The least deprived SES quintile waited the longest, although the absolute difference was small. This study demonstrates that publicly-funded healthcare systems can provide equitable access to surgical care across SES.
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Affiliation(s)
- Tyler J Law
- Center for Health Equity in Surgery and Anesthesia, University of California, San Francisco, USA. .,Department of Anesthesia & Periopative Care, University of California, San Francisco, USA. .,Zuckerberg San Francisco General Hospital, San Francisco, USA.
| | - Derek Stephens
- Department of Biostatistics, University of Toronto, Toronto, Canada.,The Hospital for Sick Children, Toronto, Canada
| | - James G Wright
- Nuffield Department of Orthopedics, Rheumatology and Musculoskeletal Science, University of Oxford, Oxford, UK.,Ontario Medical Association, Toronto, Canada
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Schemitsch E, Adachi JD, Brown JP, Tarride JE, Burke N, Oliveira T, Slatkovska L. Hip fracture predicts subsequent hip fracture: a retrospective observational study to support a call to early hip fracture prevention efforts in post-fracture patients. Osteoporos Int 2022; 33:113-122. [PMID: 34379148 PMCID: PMC8354846 DOI: 10.1007/s00198-021-06080-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 07/20/2021] [Indexed: 01/06/2023]
Abstract
In this real-world retrospective cohort, subsequent hip fracture occurred in one in four patients with any initial fracture, most often after hip fracture, on average within 1.5 years. These data support the need for early post-fracture interventions to help reduce imminent hip fracture risk and high societal and humanistic costs. PURPOSE This large retrospective cohort study aimed to provide hip fracture data, in the context of other fractures, to help inform efforts related to hip fracture prevention focusing on post-fracture patients. METHODS A cohort of 115,776 patients (72.3% female) aged > 65 (median age 81) with an index fracture occurring at skeletal sites related to age-related bone loss between January 1, 2011, and March 31, 2015, was identified using health services data from Ontario, Canada, and followed until March 31, 2017. RESULTS Hip fracture was the most common second fracture (27.8%), occurring in ≥ 19% of cases after each index fracture site and most frequently (33.0%) after hip index fracture. Median time to a second fracture of the hip was ~ 1.5 years post-index event. Patients with index hip fracture contributed the most to fracture-related initial surgeries (64.1%) and post-surgery complications (71.9%) and had the second-highest total mean healthcare cost per patient in the first year after index fracture ($62,793 ± 44,438). One-year mortality (any cause) after index hip fracture was 26.2% vs. 15.9% in the entire cohort, and 25.9% after second hip fracture. CONCLUSION A second fracture at the hip was observed in one in four patients after any index fracture and in one in three patients with an index hip fracture, on average within 1.5 years. Index hip fracture was associated with high mortality and post-surgery complication rates and healthcare costs relative to other fractures. These data support focusing on early hip fracture prevention efforts in post-fracture patients.
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Affiliation(s)
- Emil Schemitsch
- Division of Orthopaedic Surgery, Western University, London, ON, Canada
| | | | - Jacques P Brown
- CHU de Québec Research Centre and Laval University, Québec, QC, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Pincus D, Widdifield J, Palmer KS, Paterson JM, Li A, Huang A, Wasserstein D, Lapointe-Shaw L, Brown A, Taljaard M, Ivers NM. Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis. BMC Health Serv Res 2021; 21:576. [PMID: 34120597 PMCID: PMC8201723 DOI: 10.1186/s12913-021-06601-2] [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] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery. Methods This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends. Results The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was − 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours − 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy. Conclusions We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06601-2.
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Affiliation(s)
- Daniel Pincus
- Department of Surgery, University of Toronto, 149 College Street, Room 508-A, ON, M5T 1P5, Toronto, Canada. .,ICES, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,Holland Bone & Joint Program, Sunnybrook Research Institute, Toronto, Canada.
| | - Jessica Widdifield
- ICES, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Karen S Palmer
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - J Michael Paterson
- ICES, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Alvin Li
- ICES, Toronto, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - David Wasserstein
- Department of Surgery, University of Toronto, 149 College Street, Room 508-A, ON, M5T 1P5, Toronto, Canada.,Holland Bone & Joint Program, Sunnybrook Research Institute, Toronto, Canada
| | - Lauren Lapointe-Shaw
- ICES, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adalsteinn Brown
- ICES, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Noah M Ivers
- ICES, Toronto, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
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Choi JV, Cheung RM, Mozel MR, Merchant RN, Lee SM. Perioperative outcomes following preoperative epidural analgesia in hip fracture patients undergoing surgical repair: A systematic review. PAIN MEDICINE 2021; 23:234-245. [PMID: 34022058 DOI: 10.1093/pm/pnab176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the effectiveness and safety of epidural analgesia in the presurgical period on hip fracture patients undergoing surgical repair. DESIGN Systematic review. METHODS The study protocol was registered with the PROSPERO systematic reviews register: CRD42019140396. Electronic databases were searched for randomized controlled trials comparing preoperative epidural analgesia to other forms of pain management in hip fracture patients. The primary outcomes included perioperative cardiac events and mortality. Pain, non-cardiac complications, and adverse effects were also examined as secondary outcomes. Heterogeneity of the included studies was assessed using the I2 statistic and a random-effects meta-analysis was conducted once sufficient homogeneity was demonstrated. RESULTS Four studies met the inclusion criteria, which included a total of 221 patients. Preoperative epidural analgesia resulted in fewer cardiac events, which was a reported outcome in two included studies (RR 0.30; 95% CI 0.14-0.63; I2 = 0%). Preoperative epidural analgesia was also associated with decreased perioperative mortality in a meta-analysis of two studies (RR 0.13; 95% CI 0.02-0.98; I2 = 0%). Pain was not pooled due to variability in assessment methods, but preoperative epidural analgesia was associated with reduced pain in all four studies. CONCLUSIONS Preoperative epidural analgesia for hip fracture may reduce perioperative cardiac events and mortality, but the number of included studies in this systematic review was low. More research should be done to determine the benefit of early epidural analgesia for hip fractured patients.
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Affiliation(s)
- Jonathan V Choi
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia. Orcid ID: 0000-0002-5341-2397
| | - Rachel M Cheung
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia
| | | | - Richard N Merchant
- Department of Anesthesia, Royal Columbian Hospital; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia Orcid ID: 0000-0002-8526-2477
| | - Susan M Lee
- Department of Anesthesia, Royal Columbian Hospital; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia Orcid ID: 0000-0001-9016-310X
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11
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Frenkel A, Zeldetz V, Gat R, Binyamin Y, Acker A, Frenkel M, Klein M, Novack V, Schwarzfuchs D. Atrial Fibrillation and Mortality in the Oldest Old after Surgery for Hip Fractures. Gerontology 2021; 67:299-305. [PMID: 33596580 DOI: 10.1159/000513450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 11/28/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION One-year mortality following hip fractures increases steeply with age, from 2% in the 60- to 69-year-old population up to 28% in the oldest old (older than 90 years). Of the various factors that contribute to hip fractures, atrial fibrillation (AF) is an independent risk factor at any age. OBJECTIVE The objective of this study was to assess the association of AF with mortality among the oldest old with hip fractures. METHOD This is a retrospective cohort study of 701 persons above age 90 years who underwent orthopedic repair for a hip fracture during 2000-2018. Of them, 218 (31%) had AF at hospital admission. The primary outcome was survival following surgery. We compared patient characteristics and 30-day, 180-day, 1-year, and 3-year survival between patients with and without AF. RESULTS The adjusted odds ratio for 30-day postoperative mortality for those with AF versus without AF group was 1.03 (95% confidence interval [CI] 0.63-1.66). Survival estimates were higher among those without AF than with AF at 180 days postoperative: 0.85 (95% CI 0.82-0.89) versus 0.68 (95% CI 0.61-0.74), p < 0.001; at 1 year postoperative: 0.68 (95% CI 0.63-0.72) versus 0.48 (95% CI 0.42-0.55), p < 0.001; and at 3 years postoperative: 0.47 (95% CI 0.42-0.52) versus 0.28 (95% CI 0.27-0.34), p < 0.001. CONCLUSIONS Among individuals aged >90 years, operated for hip fractures, mortality was similar for those with and without AF at 30 days postoperative. However, the survival curves diverged sharply after 180 days. Our findings suggest that AF is not an immediate surgical risk factor, but rather confers increased long-term risk in this population.
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Affiliation(s)
- Amit Frenkel
- General Intensive Care Unit, Soroka University Medical Center, Beer-Sheva, Israel, .,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel,
| | - Vladimir Zeldetz
- Emergency Medicine Department, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Roni Gat
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yair Binyamin
- Department of Anesthesiology, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Asaf Acker
- Orthopedic Surgery Department, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Merav Frenkel
- Endocrine Unit, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Moti Klein
- General Intensive Care Unit, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Schwarzfuchs
- Emergency Medicine Department, Soroka University Medical Center, Beer-Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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12
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Zaragoza Sosa D, González Laureani J, King Martínez AC. Fractura de cadera en adultos mayores: Impacto del tratamiento quirúrgico oportuno en la morbimortalidad. REVISTA DE LA FACULTAD DE MEDICINA 2020. [DOI: 10.22201/fm.24484865e.2019.62.6.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Hip fracture, may occur in the femoral head, neck or in the intertrochanteric line. It is one of the most important causes of morbidity and mortality in elderly patients and it affects the physical, mental, functional and social equilibrium of these patients. Up to 50% of patients with hip fracture die in the first six months after the injury and many of those who survive don’t recover their previous level of independence and functionality. Early surgical resolution diminishes mortality and complications. Every two days that the surgery is postponed doubles the risk of death. Case report study: A 74-year-old female patient who presented a fall from her own height, is rendered incapable of walking and presents progressive pain in her right hip. She consults an orthopedic doctor for examination 42 days after the fall. Physical examination: right pelvic lower limb with an external rotation and a 1 cm shortness, hip mobility arches limited by pain. Muscle group strength was not examined because of the pain. An AP x-ray of the pelvis was performed that showed a simple trace at subcapital level on the right hip. A total arthroplasty of the right hip was performed 52 days after the patient’s fall. Conclusions: Hip fracture is a common problem in elderly patients and is associated with a high morbimortality. It is important to handle these cases early to diminish the risk of complications and mortality.
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Affiliation(s)
- Daniela Zaragoza Sosa
- Secretaría de Salud (Ssa), Hospital General "Dr. Manuel Gea González", División de Ortopedia, Médico pasante de servicio social, Ciudad de México, México
| | - Jesús González Laureani
- Secretaría de Salud (Ssa), Hospital General "Dr. Manuel Gea González", División de Ortopedia, Ciudad de México, México
| | - Ana Cristina King Martínez
- Secretaría de Salud (Ssa), Hospital General "Dr. Manuel Gea González", División de Ortopedia, Ciudad de México, México
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13
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Crawford ZT, Southam B, Matar R, Avilucea FR, Bowers K, Altaye M, Archdeacon MT. A Nomogram for Predicting 30-day Mortality in Elderly Patients Undergoing Hemiarthroplasty for Femoral Neck Fractures. Geriatr Orthop Surg Rehabil 2020; 11:2151459320960087. [PMID: 33117596 PMCID: PMC7573749 DOI: 10.1177/2151459320960087] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/30/2020] [Accepted: 08/27/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Femoral neck fractures in the elderly are increasingly common as a result of a growing geriatric population with 1-year mortality rates approaching 35%. While preoperative medical optimization and early time to surgery have reduced morbidity and mortality, patients with numerous medical comorbidities remain high risk for death in the perioperative period. Identifying those with greatest risk with a scoring system or nomogram may assist multidisciplinary teams in reducing mortality following hemiarthroplasty. Purpose Identify predictors of 30-day mortality in elderly patients who underwent hemiarthroplasty for a femoral neck fracture to generate a predictive nomogram to determine the probability of post-operative mortality. Methods Retrospective evaluation using data from the ACS-NSQIP database from 2005 to 2014 with CPT code 27125 for hip hemiarthroplasty. Multiple factors including demographics and comorbidities were compared in patients who experienced 30-day mortality and those who did not. T-test and chi-square tests were used to analyze data and a multivariate model was generated using logistic regression. Results Advanced age (odds ratio (OR) 1.04), underweight BMI (OR 1.55), male sex (OR 1.80), reduced functional status (OR 2.04), heart failure within 30 days prior to surgery (OR 2.22), American Society of Anesthesiologists grade > 2 (OR > 2.50), disseminated cancer (OR 3.43) were all found to have statistically significant odds ratios for 30-day mortality following hemiarthroplasty. Conclusion A tool based on easily identifiable risk factors, demographics, and comorbidities was developed that can help predict elderly patients who will experience mortality within 30 days of following hemiarthroplasty. In addition to identifying high risk patients, the nomogram can serve as a counseling tool for physicians to use with patients and their families to assist with better understanding of perioperative mortality risk.
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Affiliation(s)
| | - Brendan Southam
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert Matar
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Katherine Bowers
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mekibib Altaye
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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14
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Pincus D, Ravi B. Accelerated surgery for hip fractures-the HIP ATTACK results discussed. Lancet 2020; 396:1330. [PMID: 34338205 DOI: 10.1016/s0140-6736(20)31362-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/08/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Daniel Pincus
- University of Toronto Faculty of Medicine, Toronto, ON M5S 1A8, Canada.
| | - Bheeshma Ravi
- University of Toronto Faculty of Medicine, Toronto, ON M5S 1A8, Canada
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15
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de Jong L, van Rijckevorsel V, Klem TMAL, Kuijper M, Roukema GR. Prospective cohort protocol examining the perioperative indicators for complications and early mortality following hip fracture surgery in the frail patient. BMJ Open 2020; 10:e038988. [PMID: 32994255 PMCID: PMC7526269 DOI: 10.1136/bmjopen-2020-038988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The primary aim is to validate earlier suggested risk factors and to find new associated risk factors for (30-day) mortality after a hip fracture in the frail population. The secondary aim is to determine the factors associated with perioperative complications. At last we want to develop and validate a more specific 30-day mortality prediction tool compared with the Nottingham Hip Fracture Score. The 30-day mortality prediction can help inform surgical risk and guide shared decision-making among patients, family and physicians. METHODS AND ANALYSIS The study is designed as a prospective multicentre cohort study within the area of Rotterdam, the Netherlands starting from January 2018. All patients over 65 years of age, with an acute proximal hip fracture, are included. Treatment of patients will be by standard practice of care using the latest national and international guidelines. Inclusion will be continued at least until January 2021 and including at least 2500 patients. In this large cohort we hope to have sufficient strength and quality to identify risk factors of 30-day mortality and to compare them to known risk factors in literature. Moreover, we plan to develop and validate a 30-day mortality prediction tool, which identifies patients with a high probability of 30-day mortality. ETHICS AND DISSEMINATION Ethical approval for this protocol was given by the Ethics Committee of the Maasstad Hospital (TWOR). Patient data are stored anonymously using the Castor data management system. No external funding is used for this study. Results will be published in peer-reviewed publications and at international conferences. TRIAL REGISTRATION NUMBER NL8313.
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Affiliation(s)
- Louis de Jong
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Taco M A L Klem
- Department of Surgery, Franciscus Gasthuis en Vlietland Hospital, Rotterdam, The Netherlands
| | - Martijn Kuijper
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Gert R Roukema
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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16
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Merchán-Galvis Á, Muñoz DA, Solano F, Velásquez JC. Delay in hip fracture surgery and its outcomes. A reflection. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.5554/22562087.e915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hip fracture is one of the major public healthcare problems in elderly patients around the world, mainly because of the risk of falls and osteoporosis which are typical during this stage of life, and may be the cause for up to 36% of deaths among those affected. Its management in principle is surgical and the best results are achieved with patients undergoing surgery during the first 24 to 72 after the fracture. Any delays in surgery are mostly associated with decompensated personal pathological factors, delays in perioperative assessment, or in presurgical complementary tests; sometimes, the delays are the result of administrative formalities of the healthcare providers. These determining factors may affect both morbidity and mortality, and contribute to functional decline, disability, and reduced quality of life of these patients. A third party intervention is then necessary to improve the preventable factors that delay the osteosynthesis in these types of fractures, in addition to ensuring education, infrastructure, inputs, skilled human resources, and prompt referral of patients from the first level of care. Investigating this scenario and assessing the quality of life impact on these patients should be a priority.
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17
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Hospital resources do not predict accuracy of secondary trauma triage: A population-based analysis. J Trauma Acute Care Surg 2020; 88:230-241. [PMID: 31999654 DOI: 10.1097/ta.0000000000002552] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The identification of patients who require transfer from non-trauma centers to trauma centers (secondary triage) is complicated by high rates of undertriage and overtriage. The objective of this study was to evaluate variations in secondary triage accuracy across non-trauma centers and identify factors associated with highly accurate secondary triage. METHODS We performed a population-based study of injured patients who presented to non-trauma centers in a large regional trauma system. Patients were categorized as undertriaged, overtriaged, or appropriately triaged based on transfer status and presence of a severe injury (Injury Severity Score >15, death within 24 hours, or critical injury as defined by the American College of Surgeons). Mixed-effect models, adjusted for case mix and hospital resource, were used to compare triage accuracy across hospitals and identify factors associated with high-performing centers. RESULTS Among 118,973 patients identified at 182 non-trauma centers, 37,528 (31.5%) had severe injuries. The majority (76.9%) of severely injured patients were not transferred to a trauma center (undertriaged), while 9.6% of nonseverely injured patients were transferred to a trauma center (overtriaged). Mixed-effect models demonstrated that at the average hospital severely injured patients were 3.76 times more likely to be transferred than nonseverely injured patients (diagnostic odds ratio, 3.76; 95% confidence interval, 3.20-4.31). Despite significant variation in triage accuracy across hospitals, adjusted analyses suggested that local resources bore no relationship to triage accuracy. CONCLUSION Triage accuracy varies significantly across non-trauma centers, after adjusting for hospital resources. These findings suggest that other potentially modifiable factors play a key role in transfer decisions. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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18
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Skjold C, Møller AM, Wildgaard K. Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis. Acta Anaesthesiol Scand 2020; 64:23-33. [PMID: 31596943 DOI: 10.1111/aas.13491] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. METHODS Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. RESULTS We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. CONCLUSIONS The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.
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Affiliation(s)
- C. Skjold
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| | - A. M. Møller
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
| | - K. Wildgaard
- Department of Anaesthesiology Herlev Anaesthesia Critical and Emergency Care Science Unit Herlev Denmark
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19
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McGillion MH, Lin-Rogano L, Borges FK. Patient engagement in research related to accelerated surgical care and treatment for hip fracture. CMAJ 2019; 190:S38-S39. [PMID: 30404850 DOI: 10.1503/cmaj.180447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Michael H McGillion
- McMaster University (McGillion, Borges); Population Health Research Institute (McGillion, Borges); patient partner (Lin-Rogano), Hamilton, Ont.
| | - Lee Lin-Rogano
- McMaster University (McGillion, Borges); Population Health Research Institute (McGillion, Borges); patient partner (Lin-Rogano), Hamilton, Ont
| | - Flavia Kessler Borges
- McMaster University (McGillion, Borges); Population Health Research Institute (McGillion, Borges); patient partner (Lin-Rogano), Hamilton, Ont
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20
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Wu X, Tian M, Zhang J, Yang M, Gong X, Liu Y, Li X, Lindley RI, Anderson M, Peng K, Jagnoor J, Ji J, Wang M, Ivers R, Tian W. The effect of a multidisciplinary co-management program for the older hip fracture patients in Beijing: a "pre- and post-" retrospective study. Arch Osteoporos 2019; 14:43. [PMID: 30903390 DOI: 10.1007/s11657-019-0594-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/12/2019] [Indexed: 02/03/2023]
Abstract
UNLABELLED Hip fracture becomes a major public health issue with the growing aging population. This study evaluated a multidisciplinary co-management program for older hip fracture patients and found it significantly improved the best practice indicators. It provided preliminary evidence to support the use of such intervention in hip fracture management. PURPOSE/INTRODUCTION Hip fracture leads to high morbidity and mortality in older people. A previous study found a significant disparity in hip fracture management in Beijing Jishuitan Hospital (JSTH) compared to best practice care in the United Kingdom (UK). Following this audit, JSTH launched a multidisciplinary co-management care plan for older hip fracture patients. This study aims to evaluate the effect of this program on the six standards recommended in the UK hip fracture best practice guidelines. METHODS In this retrospective study, electronic medical record data were collected before and after the intervention. Eligible patients were aged ≥ 65 years, had X-ray confirmed hip fracture, and were admitted to JSTH within 30 days of injury. Patient demographic information, time from emergency department presentation to admission, time from admission to surgery, pressure ulcers, osteoporosis assessment, and falls prevention were collected. Multivariable logistic and median regression models were used for binary and continuous outcomes respectively. Segment regression was also performed for time-related outcomes. RESULTS A total of 3540 eligible patients were identified. After the intervention, half of the patients who received co-management received surgery within 48 h of ward admission compared to 6.4% previously, 0.3% (vs 1.4%) developed pressure ulcers, and 76% (vs 19%) received osteoporosis assessment. No significant differences were observed in fall assessment rates. However, there was a higher rate of ward admission within 4 h of arrival in emergency for patients admitted pre-intervention (61% vs 34%). CONCLUSIONS The introduction of the co-management model significantly reduced the time from admission to surgery and improved other practice outcomes. A multicenter randomized controlled trial is needed to evaluate the impact of this model on patient health outcomes.
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Affiliation(s)
- Xinbao Wu
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Maoyi Tian
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jing Zhang
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Minghui Yang
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Xiaofeng Gong
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Yishu Liu
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Xian Li
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Richard I Lindley
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Melanie Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Kensington, NSW, 2052, Australia
| | - Ke Peng
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Jagnoor Jagnoor
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Jiachao Ji
- The George Institute for Global Health, Peking University Health Science Center, Beijing, China
| | - Manyi Wang
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Rebecca Ivers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia. .,School of Public Health and Community Medicine, University of New South Wales, Sydney, Kensington, NSW, 2052, Australia.
| | - Wei Tian
- Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China.
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Cho N, Boland L, McIsaac DI. The association of female sex with application of evidence-based practice recommendations for perioperative care in hip fracture surgery. CMAJ 2019; 191:E151-E158. [PMID: 30745399 PMCID: PMC6370543 DOI: 10.1503/cmaj.180564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sex and gender inequality is prevalent in health care, and affects receipt of health care services and outcomes. Our objective was to measure the association between sex and receipt of evidence-based perioperative care for hip fracture in Ontario. METHODS This was a population-based retrospective cross-sectional analysis. We identified all Ontario residents aged 66 years and older who had hip fracture surgery between 2014 and 2016. After protocol registration, we measured the adjusted association between female sex and perioperative geriatric care (primary outcome), anesthesia consultations, regional analgesia and neuraxial anesthesia (secondary outcomes) using multilevel multivariable adjusted logistic regression. Pre-specified sensitivity analyses were also performed. RESULTS We identified 22 661 patients who had hip fracture surgery; 16 162 (71.3%) were women. Women were less likely to receive perioperative geriatric care (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.72 to 0.88) and anesthesia consultations (adjusted OR 0.89, 95% CI 0.80 to 0.98); women were more likely to have timely surgery (adjusted OR 1.26, 95% CI 1.17 to 1.36). Receipt of neuraxial anesthesia (adjusted OR 0.98, 95% CI 0.93 to 1.04) and regional analgesia (adjusted OR 1.00, 95% CI 0.94 to 1.07) were not different between sexes. INTERPRETATION More than 2 out of 3 patients who had hip fracture surgery were women; however, women were less likely to receive perioperative geriatric care and anesthesia consultations. Given the effectiveness of these interventions for improving outcomes, population-level hip fracture outcomes may be improved by decreasing sex-based disparities in application of evidence-based recommended perioperative care. Protocol registration: ClinicalTrials.gov, no. NCT03422497.
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Affiliation(s)
- Natalie Cho
- Department of Anesthesiology and Pain Medicine (Cho, McIsaac), and Faculty of Health Sciences (Boland), University of Ottawa; Ottawa Hospital Research Institute (McIsaac); ICES (McIsaac), Ottawa, Ont
| | - Laura Boland
- Department of Anesthesiology and Pain Medicine (Cho, McIsaac), and Faculty of Health Sciences (Boland), University of Ottawa; Ottawa Hospital Research Institute (McIsaac); ICES (McIsaac), Ottawa, Ont
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine (Cho, McIsaac), and Faculty of Health Sciences (Boland), University of Ottawa; Ottawa Hospital Research Institute (McIsaac); ICES (McIsaac), Ottawa, Ont.
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22
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Azoubel G. Focus on saving money lets patients and surgeons down. CMAJ 2018; 190:E1174. [PMID: 30274997 DOI: 10.1503/cmaj.70178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Gustavo Azoubel
- Vascular and endovascular surgeon, The Scarborough and Rouge Hospital, Scarborough, Ont., and lecturer, Division of Vascular Surgery, University of Toronto, Toronto, Ont
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