Patient-related healthcare disparities in the quality of acute hip fracture care:A 10-year nationwide population-based cohort study

OBJECTIVES: To characterise and quantify possible patient-related disparities in hip fracture care including temporal changes. DESIGN: Population-based cohort study. SETTING: All Danish hospitals treating patients with hip fracture. PARTICIPANTS: 60 275 hip fracture patients from 2007 to 2016. INTERVENTIONS: Quality of care was defined as fulfilment of eligible care process measures for the individual patient recommended by an expert panel. Using yearly logistic regression models, we predicted the individual patient’s probability for receiving high-quality care, resulting in a distribution of adjusted probabilities based on age, sex, comorbidity, fracture type, education, family mean income, migration status, cohabitation status, employment status, nursing home residence and type of municipality. Based on the distribution, we identified best-off patients (ie, the 10% of patients with the highest probability) and worst-off patients (ie, the 10% of patients with the lowest probability). We evaluated disparities in quality of care by measuring the distance in fulfilment of outcomes between the best-off and worst-off patients. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was fulfilment of all-or-none, defined as receiving all relevant process measures. Secondary outcomes were fulfilment of the individual process measures including preoperative optimisation, early surgery, early mobilisation, assessment of pain, basic mobility, nutritional risk and need for antiosteoporotic medication, fall prevention and a postdischarge rehabilitation programme. RESULTS: The proportion of patients receiving high-quality care varied over time for both best-off and worst-off patients. The absolute difference in percentage points between the best-off and worst-off patients for receiving all-or-none of the eligible process measures was 12 (95% CI 6 to 18) in 2007 and 23 (95% CI 19 to 28) in 2016. Disparities were consistent for a range of care processes, including assessment of pain, mobilisation within 24 hours, assessment of need for antiosteoporotic medication and nutritional risk assessment. CONCLUSIONS: Disparity of care between best-off and worst-off patients remained substantial over time

Opportunity to Perform - Should Simulation-Based Surgical Training be Provided on Demand or on Supply?

INTRODUCTION: The aim of the study was to assess the surgical case volume of residents before and after simulation-based training in hip fracture surgery provided on demand versus knee and shoulder arthroscopy provided on supply.MATERIALS AND METHODS: A retrospective analysis of surgical case volume in hip fracture surgery and arthroscopic shoulder and knee procedures 90 days before and after simulation-based training of either procedure. Sixty-nine orthopedic residents voluntarily participating in either simulation-based training. Hip fracture surgery simulation was provided on supply, ie, whenever 1-2 residents applied for the course, while the arthroscopic simulation course was supplied twice yearly.RESULTS: Thirty-four residents participated in hip fracture simulation on demand and 35 residents participated in arthroscopic simulation on supply. The surgical case volume of hip fracture osteosynthesis increased from median 2.5 (range: 0-21) to median 11.5 (1-17) from 90 days before to the 90 days after the simulation-based training on demand. The median difference was 6.5 procedures (p &lt; 0.0003). On the contrary, the surgical case volume in shoulder and knee arthroscopy was low both before and after the simulation on supply, ie, median 2 (0-22) before and median 1 (0-31) after. The median difference was 0 (p = 0.21).CONCLUSIONS: Simulation on demand was associated with increased opportunities to perform in the clinical environment after the simulation-based training compared with simulation on supply. Simulation-based training should be aligned with the clinical rotation of the residents. Simulation on demand instead of supply on fixed dates may overcome this organizational issue of aligning training with the opportunity to perform.</p

Are progressive shoulder exercises feasible in patients with glenohumeral osteoarthritis or rotator cuff tear arthropathy?

BACKGROUND: Little is known about the feasibility of progressive shoulder exercises (PSE) for patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA). The aim of this study was to investigate whether 12 weeks of PSE is feasible in patients with glenohumeral OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program. METHODS: Twenty patients were included. Eighteen patients (11 women, 15 with OA), mean age 70 years (range 57–80), performed 12 weeks of PSE with one weekly physiotherapist-supervised and two weekly home-based sessions. Feasibility was measured by dropout rate, adverse events, pain, and adherence to PSE. At baseline and end of intervention, patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Data to assess feasibility were analyzed using descriptive statistics. RESULTS: Two patients dropped out and no adverse events were observed. Sixteen of the eighteen patients (89%) had a high adherence (≥ 70%) to the physiotherapist-supervised sessions. Acceptable pain levels were reported; in 76% of all exercise sessions with no numeric rating scale (NRS) score over five for any exercise. WOOS improved with a mean of 23 points (95% CI 13;33), and DASH improved with a mean of 13 points (95% CI 6;19). CONCLUSION: Adherence to PSE was high and dropout rates were low. PSE is feasible, safe and may relieve shoulder pain, improve function and ROM in patients with glenohumeral OA or CTA. The patient-experienced gains after PSE seem clinically relevant and should be compared to arthroplasty surgery in a RCT setting. TRIAL REGISTRATION: According to Danish law, this study did not need an approval by the Central Denmark Region Committee on Health Research Ethics. Approval from The Danish Data Protection Agency (journal number 1-16-02-15-20) was obtained

High Cefuroxime Concentrations and Long Elimination in an Orthopaedic Surgical Deadspace—A Microdialysis Porcine Study

Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2). In a setup imitating shoulder arthroplasty surgery, but without insertion of a prosthesis, microdialysis catheters were placed for cefuroxime sampling in a deadspace in the glenohumeral joint and in cancellous bone of the scapular neck in eighteen pigs. Blood samples were collected as a reference. Cefuroxime was administered according to weight (20 mg/kg). The primary endpoint was time above the cefuroxime minimal inhibitory concentration of the free fraction of cefuroxime for Staphylococcus aureus (fT > MIC (4 μg/mL)). During the two dosing intervals, mean fT > MIC (4 μg/mL) was significantly longer in deadspace (605 min) compared with plasma (284 min) and bone (334 min). For deadspace, the mean time to reach 4 μg/mL was prolonged from the first dosing interval (8 min) to the second dosing interval (21 min), while the peak drug concentration was lower and half-life was longer in the second dosing interval. In conclusion, weight-adjusted cefuroxime fT > MIC (4 μg/mL) and elimination from the deadspace was longer in comparison to plasma and bone. Our results suggest a deadspace consolidation and a longer diffusions distance, resulting in a low cefuroxime turn-over. Based on theoretical targets, cefuroxime appears to be an appropriate prophylactic drug for the prevention of PJI

The association between first-time accreditation and the delivery of recommended care:a before and after study in the Faroe Islands

Abstract Background Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives. Methods We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012–2013 (before accreditation) or 2017–2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score. Results We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: − 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10). Conclusion Hospitals were in general more likely to provide recommended care after first-time accreditation

Consecutive cycles of hospital accreditation: Persistent low compliance associated with higher mortality and longer length of stay

Objective: To examine the association between compliance with consecutive cycles of accreditation and patient-related outcomes.Design: A Danish nationwide population-based study from 2012 to 2015.Setting: In-patients admitted with one of the 80 diagnoses at public, non-psychiatric hospitals.Participants: In-patients admitted with one of 80 primary diagnoses which accounted for 80% of all deaths occuring within 30 dyas after admission.Intervention: Admission to a hospital with high (n = 125 485 in-patients) or low compliance (n = 152 074 in-patients) in both cycles of accreditation by the Danish Healthcare Quality Programme.Main outcome measures: A 30-day mortality, length of stay (LOS) and all-cause acute readmission. We computed adjusted odds ratios (OR) and hazard ratios (HR) using logistic and Cox Proportional Hazard regression including adjustment for six potential patient-related confounders.Results: The 30-day mortality risk for in-patients admitted at high compliant hospitals was 3.95% (95% confidence interval (CI): 3.84-4.06) and 4.39% (95% CI: 4.29-4.49) at low compliant hospitals. In-patients admitted at low compliant hospitals had a substantially higher risk of dying within 30-day after admission (adjusted OR: 1.26 (95% CI: 1.11-1.43) and a longer LOS (adjusted HR of discharge: 0.89 (95% CI: 0.82-0.95) than in-patients at high compliant hospitals. No difference was seen for acute readmission (adjusted HR: 0.98 (95% CI: 0.90-1.06)). Focusing on the second cycle alone, in-patients at partially accredited hospitals had a higher 30-day mortality risk and longer LOS than admissions at fully accredited hospitals (30-day: adjusted OR: 1.12 (95% CI: 1.02-1.24) and LOS: adjusted HR: 0.91 (95% CI: 0.84-0.98)).Conclusion: Persistent low compliance with the DDKM (in Danish: Den Danske Kvalitetsmodel) accreditation was associated with higher 30-day mortality and longer LOS.</p