Data-driven development of the nationwide hip fracture registry in the Netherlands.

Additional variables for a nationwide hip fracture registry must be carefully chosen to prevent unnecessary registry load. A registry pilot in seven hospitals resulted in recommending polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for development of quality indicators. PURPOSE: Clinical registries help improve the quality of care but come at the cost of registration load. Datasets should therefore be as compact as possible; however, variables are usually chosen empirically. This study aims to evaluate potential variables with additional value to improve the nationwide Dutch Hip Fracture Audit (DHFA). METHODS: An expert panel selected eleven new variables for the DHFA, which were tested in a prospective cohort of all hip fracture patients treated in 2018 and 2019 in seven pilot hospitals participating in the DHFA. The association of these eleven variables with complications, mortality, and functional outcomes at 3 months was analyzed using multivariable logistic regression analysis. Based on the results, a proposal for variables to add to the dataset of the DHFA was made. RESULTS: In 4.904 analyzed patients, three tested variables had significant associations (p < 0.01) with outcomes: polypharmacy with complications (aOR 1.34), serum hemoglobin at admittance with complications (aOR 0.63) and mortality (aOR for 30-day mortality 0.78), and a set of questions screening for risk of delirium with complications in general (aOR 1.55), e.g., delirium (aOR 2.98), and decreased functional scores at three months (aOR 1.98). CONCLUSION: This study assesses potential new variables for a hip fracture registry. Based on the results of this study, we recommend polypharmacy, serum hemoglobin at admittance, and questions screening for risk of delirium to be used in case-mix correction and for the development of quality indicators. Incorporating these variables in the DHFA dataset may contribute to better and clinically relevant quality indicators.

Variation in treatment of hip fractures and guideline adherence amongst surgeons with different training backgrounds in the Netherlands.

BACKGROUND AND PURPOSE: Two medical specialties, general surgery and orthopaedic surgery, with different training programs but matching trauma certification requirements, provide hip fracture surgery in the Netherlands. This study analyses treatment preferences and guideline adherence of Dutch surgeons with different surgical backgrounds. PATIENTS AND METHODS: All hip fracture patients registered in the Dutch Hip Fracture Audit in 2018 and 2019 were included in this retrospective study. Four types of surgeons were distinguished: trauma-certified general surgeons (ST+), non-trauma certified general surgeons (ST-), trauma-certified orthopaedic surgeons (OT+) and non-trauma certified orthopaedic surgeons (OT-). Differences in patient characteristics, and practice variation in treatment choices and guideline adherence per fracture type were analysed using descriptive statistics. RESULTS: 28,656 patients were included; 16,367 (57.1%) treated by ST+, 1,371 (4.8%) by ST-, 4,692 (16.4%) by OT+ and 6,226 (21.7%) by OT-. Few clinically relevant differences in patient characteristics and hospital processes were found between all surgeon groups. Displaced FNF were the most commonly treated fracture type for all types of surgeons. Both OT+ and OT- operated mostly (displaced) FNFs, while the fracture types treated by ST+ and ST- were more heterogeneous. For all fracture types, the orthopaedic surgeons performed THA and HA more often than general surgeons, while general surgeons more often placed SHS and IMN for specific fracture types. Guideline adherence was on average 68.4% and differed significantly per surgeon type (68.7% by ST+, 65.2% by ST-, 74.4% by OT+ and 63.6% by OT- (p<0.01)), as well as per fracture type: >90% treatment according to the guideline for trochanteric AO-31A2 and A3 fractures, 18.8% for AO-31A1 fractures and 51.7% guideline adherence for undisplaced FNF. Guideline adherence for displaced FNF varied depending on patient characteristics. DISCUSSION: In the Netherlands, different surgical specialists treat different types of hip fractures and have different preferences concerning implants for hip fracture surgery in comparable patients. Guideline adherence of trauma- and non-trauma certified orthopaedics and general surgeons differs significantly. Reduction of practice variation should be strived for in order to improve hip fracture care.

Textbook process as a composite quality indicator for in-hospital hip fracture care.

Individual process indicators often do not enable the benchmarking of hospitals and often lack an association with outcomes of care. The composite hip fracture process indicator, textbook process, might be a tool to detect hospital variation and is associated with better outcomes during hospital stay. PURPOSE: The aim of this study was to determine hospital variation in quality of hip fracture care using a composite process indicator (textbook process) and to evaluate at patient level whether fulfilment of the textbook process indicator was associated with better outcomes during hospital stay. METHODS: Hip fracture patients aged 70 and older operated in five hospitals between 1 January 2018 and 31 December 2018 were included. Textbook process for hip fracture care was defined as follows: (1) assessment of malnutrition (2) surgery within 24 h, (3) orthogeriatric management during admission and (4) operation by an orthopaedic trauma certified surgeon. Hospital variation analysis was done by computing an observed/expected ratio (O/E ratio) for textbook process at hospital level. The expected ratios were derived from a multivariable logistic regression analysis including all relevant case-mix variables. The association between textbook process compliance and in-hospital complications and prolonged hospital stay was determined at patient level in a multivariable logistic regression model, with correction for patient, treatment and hospital characteristics. In-hospital complications were anaemia, delirium, pneumonia, urinary tract infection, in-hospital fall, heart failure, renal insufficiency, pulmonary embolism, wound infection and pressure ulcer. RESULTS: Of the 1371 included patients, 753 (55%) received care according to textbook process. At hospital level, the textbook compliance rates ranged from 38 to 76%. At patient level, textbook process compliance was significantly associated with fewer complications (38% versus 46%) (OR 0.66, 95% CI 0.52-0.84), but not with hospital stay (median length of hospital stay was 5 days in both groups) (OR 1.01, 95% CI 0.78-1.30). CONCLUSION: The textbook process indicator for hip fracture care might be a tool to detect hospital variation. At patient level, this quality indicator is associated with fewer complications during hospital stay.

Hip fracture systems-European experience.

European countries have established health care systems but are struggling with the increasing rise of fragility fractures in their aging population. In trying to address this significant burden, countries are establishing national guidelines and standards, focusing on hip fractures, which represent the significant cost for this patient group. This has evolved with the establishment of national audits and guidelines. Reports from 4 European countries (England, Italy, Netherlands, and Spain) are presented. All nations have identified both deficiencies in their systems, and protocols to improve these deficiences. When standards are introduced, there has been evidence of improved results. Significantly more work is needed to understand the key components of the systems and pathways, and efforts to study and standardize care are ongoing.

The addition of an anti-rotation screw to the dynamic hip screw.

The aim of this study is to assess if there is a difference in outcomes between a dynamic hip screw with or without an anti-rotation screw in the treatment of hip fractures. All patients with an intracapsular hip fracture who underwent dynamic hip screw osteosynthesis between January 2010 and December 2013 in three Dutch hospitals were reviewed. Minimal follow-up was one year. The study included a total of 364 patients. 24 patients were lost to follow-up and excluded. 297 (87.4%) were in the dynamic hip screw group and 43 (12.6%) in the dynamic hip with anti-rotation screw group. Direct comparison of patient characteristics of the two groups showed significant differences in age, sex, Garden classification and Pauwels classification. Patients operated with a dynamic hip screw and anti-rotation screw are significantly younger and their fractures are significantly more dislocated and steeper. To draw conclusions about differences in outcome, a randomised clinical trial should be performed.

Validation of the Fracture Mobility Score against the Parker Mobility Score in hip fracture patients.

INTRODUCTION: The Parker Mobility Score has proven to be a valid and reliable measurement of hip fracture patient mobility. For hip fracture registries the Fracture Mobility Score is advised and used, although this score has never been validated. This study aims to validate the Fracture Mobility Score against the Parker Mobility Score. PATIENTS AND METHODS: The Dutch Hip Fracture Audit uses the Fracture Mobility Score (categorical scale). For the purpose of this study, five hospitals registered both the Fracture Mobility Score and the Parker Mobility Score (0-9 scale) for every admitted hip fracture patient in 2018. The Spearman correlation between the two scores was calculated. To test whether the correlation coefficient remained stable among different patient subgroups, analyses were stratified according to baseline patient characteristics. RESULTS: In total 1,201 hip fracture patients were included. The Spearman correlation between the Fracture Mobility Score and Parker Mobility Score was strong: 0.73 (p = < 0.001). Stratified for gender, age, ASA score, dementia, Index of Activities of Daily Living (KATZ-6 ADL score), living situation and nutritional status, the correlation coefficient varied between 0.40-0.84. For patients aged 90 and over and having an ASA score of III-IV who suffered from dementia, had a KATZ-6 ADL score of 1-6, lived in an institution and/or were malnourished, the correlation was moderate. CONCLUSION: The Fracture Mobility Score is overall strongly correlated with the Parker Mobility Score and can be considered as a valid score to measure hip fracture patient mobility. This may encourage other hip fracture audits to also use the Fracture Mobility Score, which would increase the uniformity of mobility score results among national hip fracture audits and decrease the overall registration load.

Hospital staff participation in a national hip fracture audit: facilitators and barriers.

To ensure meaningful results in a clinical audit, as many hospitals as possible should participate. To optimise participation, the data collection process should either be performed by additional staff or be automated. Active participation may be promoted by offering relevant external parties insight into the actual quality of care. PURPOSE: The aim of the study was to identify which facilitators and barriers experienced by hospital staff are associated with participation in the ongoing nationwide multidisciplinary Dutch Hip Fracture Audit (DHFA). METHODS: A survey including questions about the respondents' characteristics, hospital level of participation and factors of influence on DHFA participation was sent to hip fracture surgeons. The factors were based on results of semi-structured interviews held with hospital staff involved in hip fracture care. Univariable and multivariable logistic regression analyses were used to establish which respondent characteristics and factors were associated with participation and active participation (≥ 80% of patients registered) in the DHFA. Factors significantly increasing the (active) participation in the DHFA were classified as facilitators, and factors significantly decreasing the (active) participation in the DHFA as barriers. RESULTS: One hundred nine surgeons filled out the questionnaire. The factors most agreed on were availability of staffing capacity for data collection and automated data import. A lower intention to participate was associated with being an academic surgeon (odds ratio, 0.15; 95% confidence interval, 0.04-0.52) and an orthopaedic surgeon (odds ratio, 0.30; 95% confidence interval, 0.10-0.90). Data sharing with relevant external parties was associated with active participation (odds ratio, 3.19; 95% confidence interval, 1.14-8.95). CONCLUSIONS: To improve participation in a nationwide clinical audit, it seems that the data collection should either be performed by additional staff or be automated. Active participation is facilitated if audit data is made available to other parties, such as insurers, healthcare authorities or policymakers.

The Dutch Hip Fracture Audit: evaluation of the quality of multidisciplinary hip fracture care in the Netherlands.

The nationwide Dutch Hip Fracture Audit (DHFA) is initiated to improve the quality of hip fracture care by providing insight into the actual quality of hip fracture care in daily practice. The baseline results demonstrate variance in practice, providing potential starting points to improve the quality of care. PURPOSE: The aim of this study is to describe the development and initiation of the DHFA. The secondary aim is to describe the hip fracture care in the Netherlands at the start of the audit and to assess whether there are differences in processes at baseline between hospitals. METHODS: Eighty-one hospitals were asked to register their consecutive hip fracture patients since April 2016. In 2017, the first full calendar year, the case ascertainment was determined at audit level. Three quality indicators were used to describe and assess the care process at audit and hospital level: the proportion of completed variables at discharge and at 3 months after operation, time to surgery and orthogeriatric management. RESULTS: Sixty (74%) hospitals documented 14,274 patients in the DHFA by December 2017. In 2017, the case ascertainment was 58% and the average proportion of completed variables was 77%: 91% at discharge and 30% at 3 months. The median time to operation was 18 h (IQR 7-23) for American Society of Anesthesiologists score (ASA) 1-2 patients and 21 h (IQR 13-27) for ASA 3-4 patients. Of patients aged 70 years and older, 78% received orthogeriatric management. At hospital level, all three indicators showed significant practice variance. CONCLUSION: Not all hospitals participate in the DHFA, and the data gathering process needs to be further optimized. However, the baseline results demonstrate an apparent variance in hip fracture practice between hospitals in the Netherlands, providing potential starting points to improve the quality of hip fracture care.

[Optimal timing of a hip fracture operation]. / Optimale tijdsduur tot operatie bij een heupfractuur.

There is an ongoing discussion about optimal timing of hip fracture surgery and much has been published about this subject. There is no literature-based consensus regarding the timeframe in which a hip fracture patient should be operated on; nonetheless, the National Health Care Institute in the Netherlands has been using 'time to operation' as a quality indicator since 2017. Analysis of the data from the Health and Youth Care Inspectorate on the quality indicator 'Percentage of patients operated on within one calendar day' showed that in Dutch hospitals 93% of the ASA grade 1-2 patients and 86% of the ASA grade > 2 patients were operated on within one calendar day. Delay of surgery due to preoperative optimisation of the patient is not associated with an increased mortality. The chance of complications, such as pneumonia or pressure sores, does increase with delay.

Trauma surgery by general surgeons: Still an option for proximal femoral fractures?

INTRODUCTION: Surgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored. METHODS: Patients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were>170/year (high volume), 96-170/year (medium volume) and <96/year (low volume). RESULTS: In 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p=0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580-0.958; p=0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995-0.999; p=0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997-1.018; p=0.175). CONCLUSION: Surgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.