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van der Linde M, Salet N, van Leeuwen N, Lingsma HF, Eijkenaar F. Between-hospital variation in indicators of quality of care: a systematic review. BMJ Qual Saf 2024; 33:443-455. [PMID: 38395610 DOI: 10.1136/bmjqs-2023-016726] [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: 09/14/2023] [Accepted: 01/17/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Efforts to mitigate unwarranted variation in the quality of care require insight into the 'level' (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims to synthesise the results of studies that quantify the extent to which hospitals contribute to variation in quality indicator scores. METHODS Embase, Medline, Web of Science, Cochrane and Google Scholar were systematically searched from 2010 to November 2023. We included studies that reported a measure of between-hospital variation in quality indicator scores relative to total variation, typically expressed as a variance partition coefficient (VPC). The results were analysed by disease category and quality indicator type. RESULTS In total, 8373 studies were reviewed, of which 44 met the inclusion criteria. Casemix adjusted variation was studied for multiple disease categories using 144 indicators, divided over 5 types: intermediate clinical outcomes (n=81), final clinical outcomes (n=35), processes (n=10), patient-reported experiences (n=15) and patient-reported outcomes (n=3). In addition to an analysis of between-hospital variation, eight studies also reported physician-level variation (n=54 estimates). In general, variation that could be attributed to hospitals was limited (median VPC=3%, IQR=1%-9%). Between-hospital variation was highest for process indicators (17.4%, 10.8%-33.5%) and lowest for final clinical outcomes (1.4%, 0.6%-4.2%) and patient-reported outcomes (1.0%, 0.9%-1.5%). No clear pattern could be identified in the degree of between-hospital variation by disease category. Furthermore, the studies exhibited limited attention to the reliability of observed differences in indicator scores. CONCLUSION Hospital-level variation in quality indicator scores is generally small relative to residual variation. However, meaningful variation between hospitals does exist for multiple indicators, especially for care processes which can be directly influenced by hospital policy. Quality improvement strategies are likely to generate more impact if preceded by level-specific and indicator-specific analyses of variation, and when absolute variation is also considered. PROSPERO REGISTRATION NUMBER CRD42022315850.
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Affiliation(s)
| | - Nèwel Salet
- Erasmus Universiteit Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
| | | | - Hester F Lingsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Frank Eijkenaar
- Erasmus Universiteit Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, The Netherlands
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Change in 1-year mortality after hip fracture surgery over the last decade in a European population. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04719-4. [PMID: 36456765 PMCID: PMC9715409 DOI: 10.1007/s00402-022-04719-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVE There are scarce data on the mortality after hip fracture surgery for patients treated in the most recent years. The objective of this study was to analyze whether the overall initiatives introduced over the last decade for elderly patients with hip fractures had a positive impact on the 1-year mortality. METHODS Patients treated during 2010-2012 were compared with patients treated during 2018-2020 for all-cause 1-year mortality. Variables influencing mortality were collected based on the literature, including demographic, comorbidity, cognitive status, and preinjury physical function. Crude mortalities were compared between periods, as well as with the expected mortality in the general population adjusted for age, gender, and year of surgery using the standardized mortality ratio (SMR). A multivariate model was used to identify mortality risk factors. RESULTS 591 patients older than 65 years were treated during 2010-2012 and 642 patients during 2018-2020. The mean age increased significantly between periods (78.9 vs. 82.6 years, respectively, p = 0.001) in both genders, together with an increase in comorbidity (p = 0.014). The in-hospital mortality risk had no significant difference between periods (2.5 vs. 2.0%, p = 0.339), but the 30-day mortality risk (8.3 vs. 5.5%, p = 0.031) and 1-year mortality risk (16.1 vs. 11.9%, p = 0.023) declined significantly. However, 1-year mortality in 2020 had an excess of 1.33 in SMR. Age older than 80 years, male gender, and Charlson comorbidity index > 2 were significant predictors of 1-year mortality. CONCLUSION The important evolution achieved in the last decade for the management of patients with hip fracture surgery has led to a significant decline in 1-year mortality, but the 1-year mortality remains significantly higher compared to the general population of similar age and gender.
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Schnelle C, Jones MA. The Doctors' Effect on Patients' Physical Health Outcomes Beyond the Intervention: A Methodological Review. Clin Epidemiol 2022; 14:851-870. [PMID: 35879943 PMCID: PMC9307914 DOI: 10.2147/clep.s357927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/22/2022] [Indexed: 01/02/2023] Open
Abstract
Background Previous research suggests that when a treatment is delivered, patients’ outcomes may vary systematically by medical practitioner. Objective To conduct a methodological review of studies reporting on the effect of doctors on patients’ physical health outcomes and to provide recommendations on how this effect could be measured and reported in a consistent and appropriate way. Methods The data source was 79 included studies and randomized controlled trials from a systematic review of doctors’ effects on patients’ physical health. We qualitatively assessed the studies and summarized how the doctors’ effect was measured and reported. Results The doctors’ effects on patients’ physical health outcomes were reported as fixed effects, identifying high and low outliers, or random effects, which estimate the variation in patient health outcomes due to the doctor after accounting for all available variables via the intra-class correlation coefficient. Multivariable multilevel regression is commonly used to adjust for patient risk, doctor experience and other demographics, and also to account for the clustering effect of hospitals in estimating both fixed and random effects. Conclusion This methodological review identified inconsistencies in how the doctor’s effect on patients’ physical health outcomes is measured and reported. For grading doctors from worst to best performances and estimating random effects, specific recommendations are given along with the specific data points to report. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/rvHjVIEPVhI
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Affiliation(s)
- Christoph Schnelle
- Institute of Evidence-Based Healthcare, Bond University, Robina, QLD, 4226, Australia
| | - Mark A Jones
- Institute of Evidence-Based Healthcare, Bond University, Robina, QLD, 4226, Australia
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Viberg B, Eriksen L, Højsager KD, Højsager FD, Lauritsen J, Palm H, Overgaard S. Should Pertrochanteric and Subtrochanteric Fractures Be Treated with a Short or Long Intramedullary Nail?: A Multicenter Cohort Study. J Bone Joint Surg Am 2021; 103:2291-2298. [PMID: 34546997 DOI: 10.2106/jbjs.20.01904] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of the present multicenter cohort study was to compare the rates of reoperation in elderly patients with pertrochanteric and subtrochanteric fractures that had been treated with a short or long intramedullary nail. METHODS Eleven orthopaedic departments across Denmark delivered data that had been obtained from the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and a review of health-care records. With use of surgical procedure codes for pertrochanteric and subtrochanteric fractures that had been treated with an intramedullary nail, the DMRHF was searched to identify patients who had been ≥65 years of age between 2008 and 2013. The health-care records for patients who had had major reoperations, defined as any reoperation with the exclusion of simple hardware removal, were retrieved from the DMHFR, were reviewed for the type of intramedullary nail and missed reoperations, including peri-implant fractures, within 2 years of follow-up. Crude logistic regression analysis with adjustment for age, sex, and comorbidity was performed, yielding odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS Of 2,245 pertrochanteric fractures, 1,867 were treated with a short intramedullary nail and 378 were treated with a long intramedullary nail. The rate of major reoperations was 4.0% in the short intramedullary nail group and 6.3% in the long intramedullary nail group. This yielded a crude OR of 1.61 (1.01 to 2.60) and an adjusted OR of 1.67 (1.04 to 2.70). Of 909 subtrochanteric fractures, 308 were treated with a short intramedullary nail and 601 were treated with a long intramedullary nail. The rate of major reoperations was 8.4% in the short intramedullary nail group and 4.0% in the long intramedullary nail group, yielding a crude OR of 0.45 (0.25 to 0.80) and an adjusted OR of 0.45 (0.25 to 0.81). CONCLUSIONS This is the first study confirming the theory that, for subtrochanteric fractures, a long intramedullary nail has a lower rate of major reoperations compared with a short intramedullary nail. In contrast, a short intramedullary nail has a lower rate of major reoperations compared with a long intramedullary nail for pertrochanteric fractures but with a lower absolute risk reduction compared with the results for subtrochanteric intramedullary nailing. There is a need for validation of these results in other large studies, especially for pertrochanteric fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bjarke Viberg
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt, University Hospital of Southern Denmark, Kolding, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lasse Eriksen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt, University Hospital of Southern Denmark, Kolding, Denmark
| | - Katia D Højsager
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Frederik D Højsager
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Orthopaedic Surgery and Traumatology, Hospital Lillebaelt, University Hospital of Southern Denmark, Kolding, Denmark
| | - Jens Lauritsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Henrik Palm
- Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.,Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Søren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Vesterager JD, Kristensen PK, Petersen I, Pedersen AB. Hospital variation in the risk of infection after hip fracture surgery: a population-based cohort study including 29,598 patients from 2012-2017. Acta Orthop 2021; 92:215-221. [PMID: 33334210 PMCID: PMC8158240 DOI: 10.1080/17453674.2020.1863688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Understanding the key drivers of hospital variation in postoperative infections after hip fracture surgery is important for directing quality improvements. Therefore, we investigated variation in the risk of any infection, and subgroups of infections including pneumonia and sepsis after hip fracture surgery.Methods - In this nationwide population-based cohort study, all Danish patients aged ≥ 65 undergoing surgery for an incident hip fracture from 2012 to 2017 were included. Risk of postoperative infections, based on data from hospital registration (hospital-treated infections) and antibiotic dispensing (community-treated infections), were calculated using multilevel Poisson regression analysis. Hospital variation was evaluated by intra-class coefficient (ICC) and median risk ratio (MRR).Results - The risk of hospital-treated infection was 15%. The risk of community-treated infection was 24%. The adjusted risk varied between hospitals from 7.8-25% for hospital-treated infection and 16-34% for community-treated infection. The ICC indicated that 19% of the adjusted variance was due to hospital level for hospital-treated infection. The ICC for community-treated infections was 13%. The MRR showed a 2-fold increased risk for the average patient acquiring a hospital-treated infection at the highest risk hospital compared with the lowest risk hospital. For community-treated infection, the MRR was 1.4.Interpretation - Our results suggest that 20% of infections could be reduced by applying the top performing hospitals' approach. Nearly a 5th of the variation was at the hospital level. This suggests a more standardized approach to avoid postoperative infection after hip fracture surgery.Hip fracture is a leading cause of hospital admission among the elderly. The 30-day mortality following hip fracture surgery has been approximately 10% during the last few years in Denmark (Pedersen et al. 2017). Higher mortality after hip fracture has been associated with a range of hospital factors (Kristensen et al. 2016, Sheehan et al. 2016) and patient factors in observational studies (Roche et al. 2005). Furthermore, variation in 30-day mortality after hip fracture surgery has been observed between Danish hospitals, but not fully explained (Kristensen et al. 2019).
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Affiliation(s)
- Jeppe Damgren Vesterager
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark; ,Correspondence:
| | - Pia Kjaer Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark; ,Department of Orthopedic Surgery, Regional Hospital Horsens, Horsens, Denmark;
| | - Irene Petersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark; ,epartment of Primary Care and Population health, University College London, London, UK
| | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark;
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Kristensen PK, Perez-Vicente R, Leckie G, Johnsen SP, Merlo J. Disentangling the contribution of hospitals and municipalities for understanding patient level differences in one-year mortality risk after hip-fracture: A cross-classified multilevel analysis in Sweden. PLoS One 2020; 15:e0234041. [PMID: 32492053 PMCID: PMC7269247 DOI: 10.1371/journal.pone.0234041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022] Open
Abstract
Background One-year mortality after hip-fracture is a widely used outcome measure when comparing hospital care performance. However, traditional analyses do not explicitly consider the referral of patients to municipality care after just a few days of hospitalization. Furthermore, traditional analyses investigates hospital (or municipality) variation in patient outcomes in isolation rather than as a component of the underlying patient variation. We therefore aimed to extend the traditional approach to simultaneously estimate both case-mix adjusted hospital and municipality comparisons in order to disentangle the amount of the total patient variation in clinical outcomes that was attributable to the hospital and municipality level, respectively. Methods We determined 1-year mortality risk in patients aged 65 or above with hip fractures registered in Sweden between 2011 and 2014. We performed cross-classified multilevel analysis with 54,999 patients nested within 54 hospitals and 290 municipalities. We adjusted for individual demographic, socioeconomic and clinical characteristics. To quantify the size of the hospital and municipality variation we calculated the variance partition coefficient (VPC) and the area under the receiver operator characteristic curve (AUC). Results The overall 1-year mortality rate was 25.1%. The case-mix adjusted rates varied from 21.7% to 26.5% for the 54 hospitals, and from 18.9% to 29.5% for the 290 municipalities. The VPC was just 0.2% for the hospital and just 0.1% for the municipality level. Patient sociodemographic and clinical characteristics were strong predictors of 1-year mortality (AUC = 0.716), but adding the hospital and municipality levels in the cross-classified model had a minor influence (AUC = 0.718). Conclusions Overall in Sweden, one-year mortality after hip-fracture is rather high. However, only a minor part of the patient variation is explained by the hospital and municipality levels. Therefore, a possible intervention should be nation-wide rather than directed to specific hospitals or municipalities.
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Affiliation(s)
- Pia Kjær Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Regional Hospital Horsens, Horsens, Denmark
- * E-mail:
| | - Raquel Perez-Vicente
- Research Unit of Social Epidemiology, Clinical Research Centre, Faculty of Medicine, Lund University, Malmö, Sweden
| | - George Leckie
- Centre for Multilevel Modelling, School of Education, University of Bristol, United Kingdom
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Juan Merlo
- Research Unit of Social Epidemiology, Clinical Research Centre, Faculty of Medicine, Lund University, Malmö, Sweden
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Kristensen PK, Röck ND, Christensen HC, Pedersen AB. The Danish Multidisciplinary Hip Fracture Registry 13-Year Results from a Population-Based Cohort of Hip Fracture Patients. Clin Epidemiol 2020; 12:9-21. [PMID: 32021467 PMCID: PMC6959215 DOI: 10.2147/clep.s231578] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/13/2019] [Indexed: 12/18/2022] Open
Abstract
AIM OF THE REGISTRY The aim of the Danish Multidisciplinary Hip Fracture Registry (DMHFR) is to collect data on processes of treatment, nursing care and rehabilitation as well as outcomes for patients with hip fracture in Denmark, and thereby monitor and improve the quality. STUDY POPULATION Hip fracture patients at age 65 or older that have undergone surgery with arthroplasty or internal fixation since 2004. MAIN VARIABLES DMHFR collects quality indicators and descriptive variables. Quality indicators include eight process performance measures within treatment, nursing care and rehabilitation, reflecting recommendations from the national clinical guideline for hip fracture patients, and three outcome measures including survival within 30-days, unplanned acute readmission within 30 days and reoperation within 2 years. Descriptive variables include a number of patient- and surgery-related characteristics. All data are collected prospectively. RESULTS By the end of 2018, the DMHFR included 86,438 hip fracture patients. Since 2006, all hospital departments in Denmark, treating patients with hip fracture, have reported improvement in quality of care and improvement in survival, and reoperation over time as well as high completeness of variables registration. CONCLUSION The DMHFR is a well-established nationwide clinical registry, which plays a key role for monitoring and improving hip fracture care in Denmark. The registry can further be linked to a range of other nationwide registries in order to answer a number of relevant clinical research questions.
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Affiliation(s)
- Pia Kjær Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Niels Dieter Röck
- Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark
| | - Helle Collatz Christensen
- Danish Clinical Quality Program (RKKP) National Clinical Registries, Frederiksberg Hospital, Frederiksberg, Denmark
| | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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