Summary: 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... Show moreSummary: 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. Show less
Background and Purpose: Two medical specialties, general surgery and orthopaedic surgery, with different training programs but matching trauma certification requirements, provide hip fracture... Show moreBackground 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. (C) 2021 The Authors. Published by Elsevier Ltd. Show less
A Summary 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... Show moreA Summary 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. Show less
The principal aim of the thesis is to define how the quality of hip fracture care should be measured and evaluated through a nationwide clinical hip fracture audit (chapter 1). To measure the... Show moreThe principal aim of the thesis is to define how the quality of hip fracture care should be measured and evaluated through a nationwide clinical hip fracture audit (chapter 1). To measure the quality of hip fracture care, adequate quality indicators are needed and the parameters in the audit database must be valid. Chapters 2 to 5 deal with quality indicators, while Chapter 6 addresses the validity of one of the audit database parameters. To evaluate the quality of hip fracture care the Dutch Hip Fracture Audit (DHFA) was developed. The initiation and the development of the DHFA are described in Chapter 7. Chapter 8 explores whether facilitators and barriers experienced by hospital staff were associated with hospital participation in the DHFA. The systematic data verification process of seven Dutch audits is described in Chapter 9. Based on the findings of the studies in this thesis, the general discussion (chapter 10) describes the most suitable measurements to assess the quality of hip fracture care through a clinical audit and whether the dataset of the DHFA in its present form is adequate to evaluate the quality of hip fracture care. Show less
Voeten, S.C.; Nijmeijer, W.S.; Vermeer, M.; Schipper, I.B.; Hegeman, J.H.; Klerk, G. de; ... ; DHFA Taskforce Study Grp 2020
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... Show moreIntroduction: 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. (C) 2019 The Author(s). Published by Elsevier Ltd. Show less
Voeten, S.C.; Nijmeijer, W.S.; Vermeer, M.; Schipper, I.B.; Hegeman, J.H.; Klerk, G. de; ... ; DHFA Taskforce Study Grp 2020
IntroductionThe 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... Show moreIntroductionThe 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. MethodsThe 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. ResultsIn total 1,201 hip fracture patients were included. The Spearman correlation between the Fracture Mobility Score and the Parker Mobility Score was strong: 0.73 (p = < 0.001). Stratified for gender, age, ASA grade, dementia, Index of Activities of Daily Living (KATZ-6 ADL score), living situation and nutritional status, the correlation coefficient varied between 0.40 and 0.84. For patients aged 90 and over, having ASA grade 3 or 4, suffering from dementia, having a KATZ-6 ADL score of 1 – 6, living in an institution and/or being 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. Show less
BackgroundClinical auditing is an emerging instrument for quality assessment and improvement. Moreover, clinical registries facilitate medical research as they provide ‘real world’ data. It is... Show moreBackgroundClinical auditing is an emerging instrument for quality assessment and improvement. Moreover, clinical registries facilitate medical research as they provide ‘real world’ data. It is important that entered data are robust and reliable. The aim of this study was to describe the evolving procedure and results of data verification within the Dutch Institute for Clinical Auditing (DICA).MethodsData verification performed on several (disease-specific) clinical registries between 2013 and 2015 was evaluated. Sign-up, sample size and process of verification were described. For each procedure, hospitals were visited by external data managers to verify registered data. Outcomes of data verification were completeness and accuracy. An assessment of the quality of data was given per registry, for each participating hospital. Using descriptive statistics, analyses were performed for different sections within the individual registries.ResultsSeven of the 21 registries were verified, involving 174 visits to hospital departments. A step-by-step description of the data verification process was provided. Completeness of data in the registries varied from 97·2 to 99·4 per cent. Accuracy of data ranged from 88·2 to 100 per cent. Most discrepancies were observed for postoperative complications (0·7–7·5 per cent) and ASA classification (8·5–11·4 per cent). Data quality was assessed as ‘sufficient’ for 145 of the 174 hospital departments (83·3 per cent).ConclusionData verification revealed that the data entered in the observed DICA registries were complete and accurate. Show less
Background. The time interval between CRT and surgery in rectal cancer patients is still the subject of debate. The aim of this study was to first evaluate the nationwide use of restaging magnetic... Show moreBackground. The time interval between CRT and surgery in rectal cancer patients is still the subject of debate. The aim of this study was to first evaluate the nationwide use of restaging magnetic resonance imaging (MRI) and its impact on timing of surgery, and, second, to evaluate the impact of timing of surgery after chemoradiotherapy (CRT) on short- and long-term outcomes.Methods. Patients were selected from a collaborative rectal cancer research project including 71 Dutch centres, and were subdivided into two groups according to time interval from the start of preoperative CRT to surgery (< 14 and ae14 weeks).Results. From 2095 registered patients, 475 patients received preoperative CRT. MRI restaging was performed in 79.4% of patients, with a median CRT-MRI interval of 10 weeks (interquartile range [IQR] 8-11) and a median MRI-surgery interval of 4 weeks (IQR 2-5). The CRT-surgery interval groups consisted of 224 (< 14 weeks) and 251 patients (>= 14 weeks), and the long-interval group included a higher proportion of cT4 stage and multivisceral resection patients. Pathological complete response rate (n = 34 [15.2%] vs. n = 47 [18.7%], p = 0.305) and CRM involvement (9.7% vs. 15.9%, p = 0.145) did not significantly differ. Thirty-day surgical complications were similar (20.1% vs. 23.1%, p = 0.943), however no significant differences were found for local and distant recurrence rates, disease-free survival, and overall survival.Conclusions. These real-life data, reflecting routine daily practice in The Netherlands, showed substantial variability in the use and timing of restaging MRI after preoperative CRT for rectal cancer, as well as time interval to surgery. Surgery before or after 14 weeks from the start of CRT resulted in similar short- and long-term outcomes. Show less
Quality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality... Show moreQuality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality indicators for hip fracture care reported in literature, hip fracture audits, and guidelines. The secondary aim was to compose a set of methodologically sound quality indicators for the evaluation of hip fracture care in clinical practice. A literature search according to the PRISMA guidelines and an internet search were performed to identify hip fracture quality indicators. The indicators were subdivided into process, structure, and outcome indicators. The methodological quality of the indicators was judged using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. For structure and process indicators, the construct validity was assessed. Sixteen publications, nine audits and five guidelines were included. In total, 97 unique quality indicators were found: 9 structure, 63 process, and 25 outcome indicators. Since detailed methodological information about the indicators was lacking, the AIRE instrument could not be applied. Seven indicators correlated with an outcome measure. A set of nine quality indicators was extracted from the literature, audits, and guidelines. Many quality indicators are described and used. Not all of them correlate with outcomes of care and have been assessed methodologically. As methodological evidence is lacking, we recommend the extracted set of nine indicators to be used as the starting point for further clinical research. Future research should focus on assessing the clinimetric properties of the existing quality indicators. Show less
