Clinical Features, Debates & Research / Débats, recherche et articles cliniques
Higher Survival of Hip Fracture Patients Treated in Larger Hospitals Boris Sobolev, PhD Professor and Head Division of Health Services and Policy, School of Population and Public Health The University of British Columbia Pierre Guy, MDCM, MBA, FRCSC Associate Professor and Head of Division of Orthopedic Trauma Department of Orthopedics The University of British Columbia, Katie Sheehan, PT, PhD Lecturer Department of Physiotherapy Division of Health and Social Care Research, King’s College London
A recent article reports variation in survival after hip fracture by place of treatment. Sheehan K.J. et al., for the Canadian Collaborative Study of Hip Fractures. In-hospital mortality after hip fracture by treatment setting. CMAJ 2016; 188 (18). The burden of breaking a hip very year, 25,000 older Canadians face disability, dependence and death after breaking a hip. In fact, hip fractures occur as frequently as common cancers resulting in severely worse outcomes: 25% never walk again, 22% never live independently, and 30% die within a year1-4. These figures have not changed in the past 15 years, and little is known about how to reduce a difference in death rates between the injured and the general population. With an aging population and people living longer lives, these figures pose a major challenge to health-care systems in Canada.
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In-hospital mortality after hip fracture by treatment setting For older men and women, withstanding the double stress of the injury and a major surgery could be an uphill battle that carries a significant risk of death even during the hospital stay5. What treatment and why it was chosen have been studied extensively in hip fracture care. We believe that in order to understand variation in outcomes of hip fracture care, we need also to consider where treatment is provided, who provides it and when it is provided. It is well established that survival after hip fracture surgery depends on age, sex, health status, characteristics of fracture and type of surgery. But the roles of the where, who and when of hip fracture care remain largely unknown. Our recent CMAJ article shows that where a person receives their treatment determines survival after hip fracture: people with broken hips were more likely to be discharged alive from a teaching hospital and a large community hospital than a small or mediumsized community hospital.
COA Bulletin ACO - Winter / Hiver 2016/2017
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No. of deaths per 1000 admissions
28
Teaching Community – large Community – medium Community – small
90
60
30
0
1
8
15
22
29
No. of inpatient days
Figure 1 Cumulative incidence of in-hospital death by inpatient days across treatment settings among all patients admitted with first hip fracture. Reproduced with permission from CMAJ.
The study used data from the Canadian Institute for Health Information to look at people 65 years or older who were admitted to hospitals in Canada for treatment of hip fracture over the period 2004–2012. We compared how often patients died during hospitalization across 165 hospitals varying by type and size6. We accounted for difference in length of stay by treatment setting. Teaching hospitals were defined as hospitals with full membership in the Association of Canadian Academic Healthcare Organizations, now part of HealthCareCAN. Community hospitals were categorized by size: large hospitals had 200 or more beds, medium hospitals had 50 to 199 beds, and small hospitals had fewer than 50 beds. For every 1000 patients with hip fracture, we found 14 and 43 fewer survivors among those admitted to medium and small community hospitals compared with teaching hospitals (Figure 1). The majority of patients had surgery to repair their fracture at the admitting hospital or after transfer to another hospital. For every 1000 patients treated surgically, we found 11 fewer survivors among those treated at medium community hospitals compared with teaching hospitals. Previous research suggests that the higher risk of death may be the result of less timely care because smaller hospitals have fewer beds, fewer staff members, or less readily available equipment. The Canadian Collaborative Study of Hip Fractures Health services research guides changes in policy and practice by revealing variations in care outcomes that cannot be explained by illness level, known benefit or patient preference. The Canadian Collaborative Study of Hip Fractures brings