Geographical variation in musculoskeletal surgical care in public hospitals in Ireland: a repeated cross-sectional study

Objective: To examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland. Design: Repeated cross-sectional study. Setting: 36 public hospitals in Ireland. Participants: Adult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012-2016). Primary outcome measure: Standardised discharge rate (SDR). Analysis: Age and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure. Results: Across 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures. Conclusions: Variation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.</p

Development of a frailty index in the Irish Hip Fracture Database

Introduction: In older people, hip fracture can lead to adverse outcomes. Frailty, capturing biological age and vulnerability to stressors, can indicate those at higher risk. We derived a frailty index (FI) in the Irish Hip Fracture Database (IHFD) and explored associations with prolonged length of hospital stay (LOS ≥ 30 days), delirium, inpatient mortality and new nursing home admission. We assessed whether the FI predicted those outcomes independently of age, sex and pre-operative American Society of Anaesthesiology (ASA) score. Materials and methods: A 21-item FI was constructed with 17 dichotomous co-morbidities, three 4-level ordinal pre-morbid functional variables (difficulty with indoor mobility, outdoor mobility, and shopping) and nursing home provenance (yes/no). The FI was computed as the proportion of items present and divided into tertiles (low, medium, high risk). Independent associations between FI and outcomes were explored with logistic regression, from which we extracted adjusted Odds Ratios (aOR) and Areas Under the Curve (AUC). Results: From 2017 to 2020, the IHFD included 14,615 hip fracture admissions, mean (SD) age 80.4 (8.8), 68.9% women. Complete FI data were available for 12,502 (85.5%). By FI tertile (low to high risk), prolonged LOS proportions were 5.9%, 16.1% and 23.1%; delirium 5.5%, 13.5% and 17.6%; inpatient mortality 0.6%, 3.3% and 10.1%; and new nursing home admission 2.2%, 5.9% and 11.3%. All associations were statistically significant (p Conclusions: A 21-item FI in the IHFD was a significant predictor of outcomes and added value to traditional risk markers. The utility of a routinely derived FI to more effectively direct limited orthogeriatric resources requires prospective investigation.</p

Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

Background: Falls in older people are common and can result in loss of confidence, fear of falling, restriction in activity and loss of independence. Causes of falls are multi-factorial. There is a paucity of research assessing the footwear characteristics among older people who are at high risk of falls, internationally and in the Irish setting. The aim of this study was to examine the proportion of older adults attending a geriatric day hospital in Ireland who were wearing incorrectly sized shoes. Methods: A consecutive sample of 111 older adults aged 60 years and over attending a geriatric day hospital in a large Irish teaching hospital was recruited. Demographic data including age, mobility, medications, co-habitation status, footwear worn at home and falls history were recorded. Shoe size and foot length were measured in millimetres using an internal shoe gauge and SATRA shoe size stick, respectively. Participants' self-reported shoe size was recorded. Footwear was assessed using the Footwear Assessment Form (FAF). A Timed Up and Go (TUG) score was recorded. Functional independence was assessed using the Nottingham Extended Activities of Daily Living (NEADL) Scale. The primary outcome of interest in this study was selected as having footwear within the suggested range (10 to 15 mm) on at least one foot. Participants who met this definition were compared to those with ill-fitting footwear on both feet using Chi-square tests, T-tests or Mann-Whitney U tests. Results: The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Overall, 72% of participants were wearing footwear that did not fit correctly on both feet, 90% had shoes with smooth, partly worn or fully worn sole treading and 67% reported wearing slippers at home. Participant age, TUG score and NEADL score were not associated with ill-fitting footwear. Conclusions: Wearing incorrectly fitting shoes and shoes with unsafe features was common among older adults attending geriatric day services in this study. A large number of participants reported wearing slippers at home.</p

The experience of recurrent fallers in the first year after stroke

Purpose: Understanding the experiences of fallers after stroke could inform falls-prevention interventions, which have not yet shown effectiveness in this population. The aim of this study was to explore the experience of recurrent fallers post-stroke in relation to recovery and living with falls. Methods: Participants who had more than one fall in the first year after stroke were identified from a prospective cohort study. The methods of grounded theory informed data collection and analysis. Semi-structured interviews were conducted, audio-recorded and transcribed. Coding was conducted and categories were developed inductively. Results: Nine stroke survivors aged 53-85 were interviewed 18-22 months post-discharge. Participants had experienced between 2 and 9 falls and one participant suffered a fracture. Three inter-linked categories were identified: (i) Judging the importance of falls by exploring cause and consequence, (ii) getting back up, and (iii) being careful. Conclusions: Stroke survivors' assessment of their own falls-risk and their individual priorities contribute to their decisions around activity participation. "Being careful" could be described as a form of self-managing falls-risk. The inclusion of self-management principles, peer-educators, and education to rise from the floor in falls-management programmes warrants investigation. Not all falls were considered equally important by participants. This could be considered when defining falls-related outcomes. Implications for Rehabilitation Healthcare professionals may be able to offer an increased sense of control to stroke survivors through education about how to avoid particular causes and consequences of falls. Falls-related advice should be specific, relevant to the individual, and respectful of their sense of identity. Being able to rise from the floor appears to be important for coping with falls and falls-risk. Professionals should be cognisant of the potential differences of opinion between stroke survivors and their families around management of falls-risk.</p