Importance Although wait times for hip fracture surgery have been linked to mortality and are being used as quality-of-care indicators worldwide, controversy exists about the duration of the wait that leads to complications. Objective To use population-based wait-time data to identify the optimal time window in which to conduct hip fracture surgery before the risk of complications increases. Design, Setting, and Participants Population-based, retrospective cohort study of adults undergoing hip fracture surgery between April 1, 2009, and March 31, 2014, at 72 hospitals in Ontario, Canada. Risk-adjusted restricted cubic splines modeled the probability of each complication according to wait time. The inflection point (in hours) when complications began to increase was used to define early and delayed surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched early and delayed surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). Exposure Time elapsed from hospital arrival to surgery (in hours). Main Outcomes and Measures Mortality within 30 days. Secondary outcomes included a composite of mortality or other medical complications (myocardial infarction, deep vein thrombosis, pulmonary embolism, and pneumonia). Results Among 42 230 patients with hip fracture (mean [SD] age, 80.1 years [10.7], 70.5% women) who met study entry criteria, overall mortality at 30 days was 7.0%. The risk of complications increased when wait times were greater than 24 hours, irrespective of the complication considered. Compared with 13 731 propensity-score matched patients who received surgery earlier, 13 731 patients who received surgery after 24 hours had a significantly higher risk of 30-day mortality (898 [6.5%] vs 790 [5.8%]; % absolute RD, 0.79; 95% CI, 0.23-1.35) and the composite outcome (1680 [12.2%]) vs 1383 [10.1%]; % absolute RD, 2.16; 95% CI, 1.43-2.89). Conclusions and Relevance Among adults undergoing hip fracture surgery, increased wait time was associated with a greater risk of 30-day mortality and other complications. A wait time of 24 hours may represent a threshold defining higher risk.

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Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery.

Background: Multimorbidity, the co-occurrence of two or more chronic conditions, is common among older adults and is known to be associated with high costs and gaps in quality of care Population-based estimates of multimorbidity are not readily available, which makes future planning a challenge We aimed to estimate the population-based prevalence and trends of multimorbidity in Ontario, Canada and to examine patterns in the co-occurrence of chronic conditions Methods: This retrospective cohort study includes all Ontarians (aged 0 to 105 years) with at least one of 16 common chronic conditions Descriptive statistics were used to examine and compare the prevalence of multimorbidity by age and number of conditions in 2003 and 2009 The co-occurrence of chronic conditions among individuals with multimorbidity was also explored Results: The prevalence of multimorbidity among Ontarians rose from 174% in 2003 to 243% in 2009, a 40% increase This increase over time was evident across all age groups Within individual chronic conditions, multimorbidity rates ranged from 44% to 99% Remarkably, there were no dominant patterns of co-occurring conditions Conclusion: The high prevalence of multimorbidity and numerous combinations of conditions suggests that single, disease-oriented management programs may be less effective or efficient tools for high quality care compared to person-centered approaches

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The increasing burden and complexity of multimorbidity.

Introduction: To determine if using a combination of hospital administrative data and ambulatory care physician billings can accurately identify patients with congestive heart failure (CHF), we tested 9 algorithms for identifying individuals with CHF from administrative data. Methods: The validation cohort against which the 9 algorithms were tested combined data from a random sample of adult patients from EMRALD, an electronic medical record database of primary care physicians in Ontario, Canada, and data collected in 2004/05 from a random sample of primary care patients for a study of hypertension. Algorithms were evaluated on sensitivity, specificity, positive predictive value, area under the curve on the ROC graph and the combination of likelihood ratio positive and negative. Results: We found that that one hospital record or one physician billing followed by a second record from either source within one year had the best result, with a sensitivity of 84.8% and a specificity of 97.0%. Conclusion: Population prevalence of CHF can be accurately measured using combined administrative data from hospitalization and ambulatory care.

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Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60990-2.pdf

Lifetime risk of developing chronic obstructive pulmonary disease: a longitudinal population study

Objectives To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified. Design Propensity score matched cohort study. Setting Ontario, Canada Participants 37 881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery. Main outcome measure The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery. Results Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204). Conclusions In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.

https://www.bmj.com/content/bmj/348/bmj.g3284.full.pdf

Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study

Chronic Obstructive Pulmonary Disease (COPD) is a common chronic respiratory disease responsible for significant morbidity and mortality. Population-based health administrative databases provide a powerful and unbiased way of studying COPD in the population, however, their ability to accurately identify patients with this disease must first be confirmed. The objective was to validate population-based health administrative definitions of COPD. Previously abstracted medical records of adults over the age of 35 randomly selected from primary care practices in Ontario, Canada were reviewed by an expert panel to establish if an individual did or did not have a diagnosis of COPD. These reference designations were then linked to each individual's respective health administrative database record and compared with predefine health administrative data definitions of COPD. Concepts of diagnostic test evaluation were used to calculate and compare their test characteristics. The most sensitive health administrative definition of COPD was 1 or more ambulatory claims and/or 1 or more hospitalizations for COPD that yielded a sensitivity of 85.0% (95% confidence interval 77.0 to 91.0) and a specificity of 78.4% (95% confidence interval 73.6 to 82.7). As number of ambulatory claims in the definition increased, sensitivity decreased and specificity increased. Individuals with COPD can be accurately identified in health administrative data, and therefore it may be used to create an unbiased population cohort for surveillance and research. This offers a powerful means of generating evidence to inform strategies that optimize the prevention and management of COPD.

C Wang

Papers

Identifying individuals with physcian diagnosed COPD in health administrative databases.