Kristensen Pia Kjær, Merlo Juan, Ghith Nermin, Leckie George, Johnsen Søren Paaske
Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N DK-8200, Denmark.
Department of Orthopedic Surgery, Regional Hospital Horsens, Horsens DK-8700, Denmark.
Clin Epidemiol. 2019 Jul 16;11:605-614. doi: 10.2147/CLEP.S213898. eCollection 2019.
Thirty-day mortality after hip fracture is widely used when ranking hospital performance, but the reliability of such hospital ranking is seldom calculated. We aimed to quantify the variation in 30-day mortality across hospitals and to determine the hospital general contextual effect for understanding patient differences in 30-day mortality risk.
Patients aged ≥65 years with an incident hip fracture registered in the Danish Multidisciplinary Fracture Registry between 2007 and 2016 were identified (n=60,004). We estimated unadjusted and patient-mix adjusted risk of 30-day mortality in 32 hospitals. We performed a multilevel analysis of individual heterogeneity and discriminatory accuracy with patients nested within hospitals. We expressed the hospital general contextual effect by the median odds ratio (MOR), the area under the receiver operating characteristics curve and the variance partition coefficient (VPC).
The overall 30-day mortality rate was 10%. Patient characteristics including high sociodemographic risk score, underweight, comorbidity, a subtrochanteric fracture, and living at a nursing home were strong predictors of 30-day mortality (area under the curve=0.728). The adjusted differences between hospital averages in 30-day mortality varied from 5% to 9% across the 32 hospitals, which correspond to a MOR of 1.18 (95% CI: 1.12-1.25). However, the hospital general context effect was low, as the VPC was below 1% and adding the hospital level to a single-level model with adjustment for patient-mix increased the area under the receiver operating characteristics curve by only 0.004 units.
Only minor hospital differences were found in 30-day mortality after hip fracture. Mortality after hip fracture needs to be lowered in Denmark but possible interventions should be patient oriented and universal rather than focused on specific hospitals.
髋部骨折后30天死亡率在对医院绩效进行排名时被广泛使用，但这种医院排名的可靠性很少被计算。我们旨在量化各医院30天死亡率的差异，并确定医院总体背景效应，以了解患者在30天死亡风险方面的差异。
确定2007年至2016年期间在丹麦多学科骨折登记处登记的年龄≥65岁的髋部骨折患者（n = 60,004）。我们估计了32家医院未调整和患者组合调整后的30天死亡风险。我们对嵌套在医院内的患者进行了个体异质性和鉴别准确性的多层次分析。我们用中位数优势比（MOR）、受试者工作特征曲线下面积和方差划分系数（VPC）来表示医院总体背景效应。
总体30天死亡率为10%。包括高社会人口学风险评分、体重过轻、合并症、转子下骨折以及住在养老院等患者特征是30天死亡率的强预测因素（曲线下面积 = 0.728）。32家医院的30天死亡率调整后平均值差异在5%至9%之间，对应的MOR为1.18（95%CI：1.12 - 1.25）。然而，医院总体背景效应较低，因为VPC低于1%，并且在对患者组合进行调整的单水平模型中加入医院水平，仅使受试者工作特征曲线下面积增加了0.
